I need a PHP programmer to complete a simple php form for registration

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Bids
64
Avg Bid (USD)
$55
Project Budget (USD)
$30 - $250

Project Description:
Registration form contain

Full Name, Blood Group, Gender,Date Of Birth,Mobile Number,Land Line Number,Select State,Select District,Select City,E-Mail ID,Permanent Address,UserId,,Password and an email link activation .

The project must be done within 4 hrs.

ITS VERY URRGEENT TO COMPLETE within 4 hrs.

HTML Template is already done. only need to write php code.

Skills required:
Graphic Design, HTML, PHP, Website Design
About the employer:
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