HTML contact form coding

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Bids
7
Avg Bid (USD)
$69
Project Budget (USD)
$30 - $250

Project Description:
I am developing a new website geared toward collecting new subscribers. I need someone to code the contact form (so I can use it on any website in the future). The form should send the new subscribed information to a database. The form must collect the originating IP address from which the person filled out the form and also include the following fields:

Email
First Name
Last Name
Address
City
Zip Code
Phone

Should be a simple enough job for someone...

Skills required:
Graphic Design, HTML, MySQL, PHP
Qualifications required:
us_eng_1 US English - Level 1
Hire bs5143
Project posted by:
bs5143 United States
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