In Progress

Form Creation 2

ALTHOUGH THIS IS LISTED AS SMALL PROJECT $250-$750 I will obviously not be paying a price like that for this form. I know that this takes under an hour; much less for a skilled developer. Please be fair with your bids. THIS IS TIME CRITICAL.

I need a form created that abides by the following criteria with no error. I need this done immediately. I will call or skype the coder if you would like. I am able to make payment immediately after seeing the script working. After payment, I request the code and scripts to function the site on my own webserver.

Nicely formatted form that requires:

First Name

Last Name

Phone Number

State (use a drop down - only need to include NJ, NY, PA, CT, NO OTHER STATES)

E-mail

Date of Birth

It requests:

Address

City

Zip

Error checking for required information

Error checking for data type, size, and basic format (especially important for date of birth)

A FORM PROCESSING PAGE: On the form processing page:

Show today's date

Echo back the visitor's age in years

If the visitor is older than 60 indicate that they are entitled to a senior citizen discount

If the visitor is 30-60 years old indicate that they are entitled to a middle aged citizen discount

If the visitor is younger than 18 indicate that they are entitle to a youth discount

Echo back the users first and last name.

For example, my results page might be something like:

Ross Malaga thank you for contacting us. Today is September 1, 2011. Since you are 44 years old you are entitled to our middle aged discount.

-- PLEASE NOTE THE AREA THAT SAYS WHAT IS REQUIRED, and WHAT IS REQUESTED.

I want to be able to upload a .html file for the form, one for the form processing page, and whatever necessary script to have this functional on my web server.

Skills: HTML

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About the Employer:
( 4 reviews ) Highland Lakes, United States

Project ID: #1239634

Awarded to:

andrawisnas

ready to start

$30 USD in 2 days
(6 Reviews)
3.3

23 freelancers are bidding on average $35 for this job

ExcellenceonPHP

I READ THE DETAILS AND READY TO START.I HAVE EXP OVER 5 YEARS ON PHP,MYSQL,JS,AJAX,[url removed, login to view] AFTER COMPLETING THE [url removed, login to view] FOR YOUR REPLY TO [url removed, login to view]

$50 USD in 1 day
(136 Reviews)
6.6
k1ng440

Professional Web Developer is ready get started right now. More information in Private Message

$50 USD in 2 days
(37 Reviews)
5.5
hutchbat

Hello, a professional web developer offers to create a custom for with PHP/Jquery validation.

$30 USD in 0 days
(54 Reviews)
5.4
abhiramgantyada

Completed the similar project as First Freelancer project with a speed bonus of $22..so it takes no time....to do this....Thank you..

$30 USD in 0 days
(23 Reviews)
5.3
SSADeveloper

i can help you,[url removed, login to view] check your pmb!

$30 USD in 0 days
(28 Reviews)
5.1
honeyweb

Please check your PMB:) Can start from Now! Thanks Madhu

$30 USD in 0 days
(45 Reviews)
5.1
gracebasilior

Hi, I can do it for you. Please see PM!

$35 USD in 0 days
(16 Reviews)
4.2
TayyabAlibin

can give you the best...

$30 USD in 1 day
(8 Reviews)
3.5
achillesJK

Hello, sir. I can help you. Also check pm.

$30 USD in 0 days
(2 Reviews)
2.5
siamsoft061

sir, ready to [url removed, login to view] your reply. Thank you

$30 USD in 0 days
(2 Reviews)
2.3
anuragjainvirus

Hi, Please check PM. I will give you the ready made script code within 30 minutes for only $25 to $29. I already have it and implemented in many websites. Contact me sir on anuragjainvirus@gmail (dot) com. Or More

$30 USD in 0 days
(0 Reviews)
0.0
dorw123

Hello sir! Please check your inbox.

$40 USD in 1 day
(0 Reviews)
0.0
revemotion

Dear Sir, I am ready to start. Please give me chance to do this. it is not a complex task so please let me do this for you. Best Regards

$35 USD in 0 days
(0 Reviews)
0.0
ishan1988

i understand your requirement and would love to work with you on it

$30 USD in 0 days
(0 Reviews)
0.0
samiejg

Hey :) I can do this for you! Sent PM.

$45 USD in 0 days
(0 Reviews)
0.0
nbtfirm

Dear Sir/Madam, We are specialized in web designing and development. We already complete a huge project, if you intarested then we can PM you our e-profile. Thank You With regards, NBT FIRM

$30 USD in 0 days
(0 Reviews)
0.0
shaunphp1208

Hi i am highly interested to dowork with you. i assure you that i will never disappointed to you.

$30 USD in 1 day
(0 Reviews)
0.0
nisargdoshi

I have understand your project requirements. These requirements basically covers form processing , client side data input validation. Basically form validation requires some regex patterns to protect invalid user More

$30 USD in 6 days
(0 Reviews)
0.0
crawfordworks

Hello there, I'm able to do this project entirely using your choice of Javascript or PHP. See PM for previous work.

$40 USD in 4 days
(0 Reviews)
0.0
BrightSoftWork

Please check PMB

$30 USD in 0 days
(0 Reviews)
0.0