php web form

Project Description:
Hello,

I need a web-form built.
There are 36 questions and there are 5 possible answers for each question. The respondents are only allowed to submit one answer per question. (radio buttons should be sufficient).
They will also need to submit their name on the form.

I want the form built in PHP - and will need it uploaded to my server (LINIX). I will need the information/answers to be sent to my email address in a format that is easy to read.
This is an easy job - I will pay up to $40 for this job. It needs to be completed in no more than 36 hours after bidding ends.
I will also need a header image at the top of the page and some other information which I will provide you with.

Please let me know if you have any questions.
Happy bidding.
Roofy.