Placeholder page with contact detail capture

Budget $30 - $250 USD
Bids 10
Average Bid $230

The business is an email service provider. We are not live yet.

I need a placeholder page with a form that lets the customer enter their name & current email address, so that I can contact them and I need a form which lets them reserve an email address.

This data needs to be stored in a database (SQlite, MySQL?)

There will need to be some sort of barrier to automated registration by bots. I'm not keen on Captcha or anything like that. Could an RBL be used?

At the end of the day this is pre-registration only and the final registration will need paying for, which spammers will not do. I simply want to avoid having my database swamped with rubbish while at the same time not putting off any genuine customers.

The form to reserve an email address should be configurable so that I can set the domain name and a list of hard coded prefixes for the local-part of the address.

eg. "___________(at)domain(dotcom)"



These should appear as drop down options with a preview of the final address.

So, the customer enters his desired local-part in one box and then next to that box is a drop down with the prefix & domain and next to that (or under it) is a preview of how the final email address with look.

There will need to be an OK button to choose the address. There should be a confirmation pop-up with the text;

You have chosen "" as your email address.


Should the "reserve an email address" functionality be in a separate page / pop-up?

I need cross browser compatibilty.

The attached design is just a suggestion. Feel free to ignore it.

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