Need to create an email list sign up form IN MYSPACE!

• Project ID:

  461206

• Project Type:

  Fixed

• Budget:

  $250-$750 USD
  

Project Description:

I need this to write the Name, Zipcode, DOB and State to a textfile on my server...
here is an example of what the form looks like
http://www.myspace.com/ashtest3

THIS MUST WORK ON MYSPACE!!!!!!!!!!!!!!!

I want a form code that works like:

<form action="link to page saying add was succesful" method="post" target="_blank">
<input type="hidden" name="signup_post" value="49706" />
<input type="hidden" name="emma_account_id" value="29463" />
<input type="hidden" name="username" value="remotekm" />
<input type="hidden" name="password" value="La1h78m*" />
<input type="hidden" name="group[6143542]" value="1" />
<tr>
<td valign="top"><table width="400" border="0" cellspacing="3" cellpadding="0">

<tr>

<td> first name </td> <td valign="top"><input name="emma_member_name_first" type="text" />
</td>
</tr>
<tr>

<td>last name</td> <td valign="top"><input name="emma_member_name_last" type="text" />
</td>
</tr>
<tr>

<td> email</b> </td> <td valign="top"><input name="emma_member_email" type="text" />
</td>
</tr>
<tr>
<td> DOB</td> <td valign="top"><select name="emma_member_dob[M]">
<option value=""> </option>
<option value="1">Jan</option>
<option value="2">Feb</option>
<option value="3">Mar</option>
<option value="4">Apr</option>
<option value="5">May</option>
<option value="6">Jun</option>
<option value="7">Jul</option>
<option value="8">Aug</option>
<option value="9">Sep</option>
<option value="10">Oct</option>
<option value="11">Nov</option>
<option value="12">Dec</option>
</select>
<select name="emma_member_dob[d]">
<option value=""> </option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select name="emma_member_dob[Y]">
<option value=""> </option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
</select></td>
</tr>
<tr>
<td> state</td>
<td valign="top"><select name="emma_member_state">
<option value=""></option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AS">AS</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="GU">GU</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="ME">ME</option>
<option value="MD">MD</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PR">PR</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
</select></td>
</tr>




</table>

*required </td>
<td></td>
</tr>

<tr>

<td colspan="3" align="center" valign="top"><input type="submit" name="Submit" value="signup" /> </td>
</tr>
</form>

Skills required:

Flex, Java, PHP, Website Design, XML