Create a Contact Form

ALTHOUGH THIS IS LISTED AS SMALL PROJECT $250-$750 I will obviously not be paying a price like that for this form. I know that this takes under an hour; much less for a skilled developer. Please be fair with your bids. THIS IS TIME CRITICAL.

I need a form created that abides by the following criteria with no error. I need this done immediately. I will call or skype the coder if you would like. I am able to make payment immediately after seeing the script working. After payment, I request the code and scripts to function the site on my own webserver.

Nicely formatted form that requires:

First Name

Last Name

Phone Number

State (use a drop down - only need to include NJ, NY, PA, CT, NO OTHER STATES)

E-mail

Date of Birth

It requests:

Address

City

Zip

Error checking for required information

Error checking for data type, size, and basic format (especially important for date of birth)

A FORM PROCESSING PAGE: On the form processing page:

Show today's date

Echo back the visitor's age in years

If the visitor is older than 60 indicate that they are entitled to a senior citizen discount

If the visitor is 30-60 years old indicate that they are entitled to a middle aged citizen discount

If the visitor is younger than 18 indicate that they are entitle to a youth discount

Echo back the users first and last name.

For example, my results page might be something like:

Ross Malaga thank you for contacting us. Today is September 1, 2011. Since you are 44 years old you are entitled to our middle aged discount.

-- PLEASE NOTE THE AREA THAT SAYS WHAT IS REQUIRED, and WHAT IS REQUESTED.

I want to be able to upload a .html file for the form, one for the form processing page, and whatever necessary script to have this functional on my web server.

Diseño gráfico HTML PHP Diseño de sitios web

Nº del proyecto: #1237689

Sobre el proyecto