Website Form to Populate SQL Database - Simple

IN PROGRESS
Bids
8
Avg Bid (USD)
$85
Project Budget (USD)
$30 - $250

Project Description:
Very Simple Project - A simple pop-up form that gathers information then stores said in sql database.

Here is current form - http://jotform.us/form/32037433717148 - Save the following data to SQL -

Username, Password, eMail Address, Referred By, Subscription Level (Standard or Division) - INVISIBLY Record IP Address, and Account # that is automatically assigned (IPU0280, IPU0281, IPU0282, etc)

REMOVE "Comments & Questions field, instead tell them to email us at .

Send receipt email with their IP Address & Account # on execution.

Use this artwork - http://i1316.photobucket.com/albums/t613/ipusboss/sigline_zps7dcdf2f4.jpg

I have database login credentials, want to get started TODAY please

Skills required:
MySQL, PHP, Software Architecture
About the employer:
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