Phonegap + JQMOBILE + PHP - 1 page

We need one page with 4 fields in each input field the user can put a remark and under it each field the user have a take a pic button After the completion of writing the remarks (1 to 4) and taking up to 4 pic the user will push a submit button then the data will be submitted to mysql database , each remark will get a unique key and picture will be loaded and each picture will get a unique key ID of the remark it related to. Phone gap 2.2.0 , the PHP page will located on the server and phonegap client will do [login to view URL] to the page (we need only the PHP page).