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Create Pop-up email sign up form for my website

I would like a page added to my website. The page is going to be a submission form for my referral program. It should collect all necessary data and send it to my email.

The form I have below is the paper copy I use. I'm open to edits but that should be the general idea.

Skills: Graphic Design, HTML, PHP, Shopping Carts, Website Design

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About the Employer:
( 0 reviews ) Ottawa, Canada

Project ID: #15215492

45 freelancers are bidding on average $124 for this job

nmans

HI There, We are ready to create a mailing list pop up for you with complete integration so you can do your desired work Relevant Skills and Experience Please get in touch so we can discuss everything in detail Pr More

$247 CAD in 3 days
(520 Reviews)
8.5
stefanprodanovic

Hi AdminOPC, i see you need some graphic design, so i"m without other projects todaz so i can start now and complete your project in few hours.. Please contact meGreetings, Stefan Relevant Skills and Experience: I'm ex More

$155 CAD in 3 days
(291 Reviews)
7.8
Chtioui86

Hi I am expert web developer I can do your changes fast and in a professional way. No payment until I finish your work. Price and Time will depend on the full details and changes Thanks Relevant Skills and Experience More

$263 CAD in 3 days
(259 Reviews)
7.8
sureshdevi

I will create popup email signup form based on your Referral Guidelines document and make it to send all necessary details to email. I will complete this work in 2 days. Relevant Skills and Experience PHP, Wordpress, More

$79 CAD in 2 days
(1101 Reviews)
8.0
VnBestSolutions

Dear Sir. I had read your descriptions about project. Kindly give me a chance, i would like to discuss more about project and sure everything clear. I am a developer very strong in below skills. Relevant Skills and Ex More

$155 CAD in 3 days
(221 Reviews)
7.0
HahaDesign

Hello! We are a team of designers and illustrators and all of us graduated the University in our domains. We are thinking outside the box so we'll find the creative solutions for your project. Relevant Skills and Expe More

$200 CAD in 3 days
(163 Reviews)
6.7
techwelfare

Hi Let's clarify the requirement in [url removed, login to view] have a few questions about your project, please send us message so that we can discuss more. Relevant Skills and Experience here is some of our prevous work you could ch More

$240 CAD in 15 days
(172 Reviews)
7.2
usin

We have good team of creative and excellent professionals in creating websites over 7 years experience with charming designs which is creative and performance effective 100% Satisfaction Guaranteed Relevant Skills and More

$100 CAD in 3 days
(122 Reviews)
6.7
transformindesi9

I will certainly ensure you will receive quality work for the project. Relevant Skills and Experience Review some of my past work on the following link: [url removed, login to view] Please cont More

$100 CAD in 2 days
(250 Reviews)
7.0
laabhaa

Hi Thank's for providing us an opportunity to bid on your project. We read you project description and understand clearly so we are highly interested to work for you Relevant Skills and Experience We specialise in PHP More

$155 CAD in 3 days
(104 Reviews)
6.8
ineedWorkJob

Greetings sir, how are you today sir? hope fine. Sir, I have read your project details and i will create a form that will popup when visition visit specific page or make action, and when all information is input More

$100 CAD in 2 days
(116 Reviews)
6.4
majid24

I can create a newsletter for you with Form Submission. Please message me the files and login details as i am available to start working on the project right away. Relevant Skills and Experience I'm an Islamabad based More

$166 CAD in 2 days
(63 Reviews)
6.7
webarox

Hi, I have 8+ years experience in Web development, I checked your attached popup content and form. It will take 2-3 hours for me to make working as you expected. I am available to start now and I will deliver you in ne More

$45 CAD in 1 day
(80 Reviews)
6.3
Max01

hello hope you are doing well I am interested to work on this project. Gladly waiting to serve you with my extensive skills. Relevant Skills and Experience php mysql Proposed Milestones $80 CAD - lets do it Plea More

$80 CAD in 2 days
(231 Reviews)
6.4
finbuks

Hello Sir/ma'am, Namaste !! I'll build a single page with pop up for your website as per your requirements and take care of all responsive issues. Please spare a moment to discuss this project. Relevant Skills and E More

$120 CAD in 2 days
(76 Reviews)
6.6
Avinavkr

Dear _____(Sir or Madam) I Mr. Avinav Kumar on behalf of  Softpointzone  is writing this letter to offer our web designing and development  services to [url removed, login to view] company excels in providing web designing and development More

$150 CAD in 2 days
(98 Reviews)
6.3
rahulhunjan99

I will add professional popup, I am ready to start the project right now, you can check my portfolio here - [url removed, login to view] Relevant Skills and Experience I'm expert in back and front-end functionalit More

$50 CAD in 3 days
(168 Reviews)
6.4
vishwanath89

Hey Would like to discuss and get my queries cleared up. Relevant Skills and Experience Have done similar work here. Thanks Vish Proposed Milestones $155 CAD - Proposed

$155 CAD in 3 days
(39 Reviews)
5.8
umesh655

A proposal has not yet been provided

$155 CAD in 5 days
(154 Reviews)
6.1
WebColorIn

Its quite easy one, lets do it. Relevant Skills and Experience Website Development, Chrome Extension, Custom WordPress Theme, SEO, Hosting & Maintenance Proposed Milestones $155 CAD - Complete

$155 CAD in 3 days
(35 Reviews)
5.9