very basic form submission website

Avg Bid (USD)
Project Budget (USD)
$30 - $250

Project Description:
Hi freelancers,

i require a quote to design a simple website. the quote should include both the coding / functionality as well as the graphic design. I have purchased the domain name but no hosting as yet. It is a simple form submission that should email through to me a persons details for me to follow up. I am using this as a salesperson to collect leads.

something like this -

Thank you for your time freelancers

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