Simple asp contact form

IN PROGRESS
Bids
71
Avg Bid (USD)
N/A
Project Budget (USD)
$30 - $250

Project Description:
Hello,

I am looking for somebody to create a simple contact form and have the information send to my e-mail address.
My website is hosted through Microsoft Office live websites so it needs to be done using ASP. I think.

Please find enclosed an image with the exact contact form that I need. I will need the same exact form in two different pages on my website.

Fields are:

Practice Name:
City:
Phone:
Email:
Contact Name:

Submit

All the fields need to be validated.
I need this done as soon as possible.
Please let me know time estimate for this,
Thank you.
AFMA

Skills required:
.NET, ASP, Javascript, PHP, Windows Desktop
Additional Files: contact_form.jpg
About the employer:
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