Web Form

We need to create a Web Form for enrollment in some educational courses. You can get an idea of some of the fields needed in the form by looking at the attached file. The form doesn't need to have the same format and half of the fields in the attached file will not be used in the form. No drop down menus are necessary. Actually the form will be much simpler than the attached file. If you already have a functional form, we can start from there and just add the required extra fields. We can actually simplify matters by just adding big fields where the user can type more info, rather than breaking up the info and using shorter fields. You can use any available open source PHP to mail, or PHP to mysql script, or simply the one you usually use for web forms. It's your choice as long as it works well, runs on linux and is not highly hackable, in which case we might have some script suggestions. Any questions please let me know.