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.