533011 Need to turn this document into a web form

IN PROGRESS
Bids
1
Avg Bid (USD)
$10
Project Budget (USD)
N/A

Project Description:
Attached Word document has an order form that needs to be converted into a web form where the data is mailed. Red letters are notes for each field.

Datepickers, checkboxes, and file upload fields will be required.

The form will be on an html website and should be processed using php.

Skills required:
Anything Goes, PHP, Shell Script
About the employer:
Verified
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