jquery/php form that stores data/mysql in wordpress

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Bids
4
Avg Bid (USD)
$95
Project Budget (USD)
$30 - $250

Project Description:
I need a jquery/php form for wordpress that pops up when someone tries to vote for an image. When it pops up, I want it to say "If you'd like your vote to count, please enter a valid email address, then a form to input email, and underneath that, a checkbox for "I would like to receive a promotional codes and discounts through email". Email needs to save in a database and has an export button inside of wordpress.

After they are done, there will be a "save vote" which will then close the window and save the vote.
http://www.brooklynbedding.com/contest/

This can be real simple and does not need to be a full fledged plugin. I won't accept any bids over $100 for this project.

Skills required:
PHP
About the employer:
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