HTML / PHP Survey Script Need TODAY - Simple!

I need this completed in the next few hours. An experienced coder can do this very quickly. Please indicate you can finish today when bidding. I need a survey page done with a logo at the top of the page and the following 3 questions centered on the page. Please use radio buttons for each selection. If the user selects 3 or below for any of the answers, they should be redirected to another PHP page ([login to view URL]) that asks them for their email address and phone number, and then sends me an email with their information. Otherwise, they should be redirected to a thank you page ([login to view URL]) that will have 3 links [login to view URL], [login to view URL] and bing.com. I also need you to provide mobile-friendly templates of all these pages that will fit an iPhone or Android screen. Survey: How would you rate your experience with your Dentist? 1 2 3 4 5 How would you rate your experience with your Technician? 1 2 3 4 5 How would you rate your overall experience at the Dentistry? 1 2 3 4 5