Landing Page (1 Pager) Form Collection of Data

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

Project Description:
I need 1 web page that will act as a form to collect data from trade shows. The page will be hosted on separate domain which will be used by people at trade shows to sign up electronically.
The information the page will collect is shown in the attachment.
Importantly, the person who does this must know how to
(1) integrate facebook, as 1 of the form options is to like our page and post on their wall a comment.
(2) verify email addresses as valid and data validation to make sure we're getting quality data.
(3) transfer the data collected into a backend module which I can use to extract data in CSV/Excel format.

The successful freelancer should also provide support in assisting me to transfer the site and host it through my private web hoster.
The form itself is quite simple as there are <5 responses required (see attached). Pretty much all of the copyrighting is provided and I'll also provide the successful freelancer with print pages of the website so they can see the design. A simple design is preferred with
Milestone payment can be scheduled however, the final milestone, will only be released upon successful deployment of the page onto the URL.
Please provide previous sample of work you have done if you've done similar things before.

This needs to be completed AT LATEST by 21 April 2013.

Skills required:
Electronic Forms, Landing Pages, Web Hosting, Website Design, Website Management
Additional Files: webpage.docx
About the employer:
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