Simple PHP Submission Form

Avg Bid (ZAR)
Project Budget (ZAR)
R210 - R1750

Project Description:
I Need a simple PHP submission form that will allow users to place orders for either a Cartridge OR Paper
Upon submission the form will need to insert these entries into a mysql table

Fields should be

(1)User Detail

User Name: (Str field)
Full Name: (Str Field)
Cell No: (reg expression verification)
Email: (verify if email is valid)
Location: (String field)

(2)Device Detail

Serial Number: (String Field) - Should have the ajax function to lookup the model of the device, if serial does not exist in table it should be added
Model:(String field)
Meter Reading:(Integer field)
Current Supply Level: (String Field)

(3)Order Detail
Paper: (Radio Button (Yes/No) - If Yes, a new field should appear with a quantity field)
Cartridge(Radio Button(Yes/No)

Image Verification(Captcha)

Submit Button

Skills required:
MySQL, PHP, Software Architecture
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