354380 Contact form - asap now

I need this form in php mailer ASAP! I need to be able to copy and paste it in a index. I need it to look like [login to view URL] .com/maxconnect without the db error. I need it to say: Who Referred You: Full Name: Email: Address: (white box) Street Address: State: (drop down with 50 states) City: Zip: Phone Number: INSTEAD OF A SUBMIT BOTTOM, I WANT IT TO SAY, NEXT. AFTER THEY HIT NEXT I WANT IT TO REDIRECT TO ANOTHER PAGET HAT I WANT PROBABLY MY HOMEPAGE. I need it to have a subject and i want to be able to send it to multiple emails. must submit demo!