In Progress

Form Creation

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: #1237730

Awarded to:

andrawisnas

expert php , html and css developer and i am ready to finish your form now please check your PMB for more details

$30 USD in 1 day
(6 Reviews)
3.3

5 freelancers are bidding on average $55 for this job

hasanrajani

Let's Start.

$30 USD in 1 day
(92 Reviews)
6.2
randdythea

hi sir,please check your PMB,thanks ^_^

$70 USD in 2 days
(91 Reviews)
5.6
GoldServices

I am sure I can help you and create the form for you!

$100 USD in 2 days
(3 Reviews)
4.4
pixlgroup

Please check your PMB.

$45 USD in 1 day
(0 Reviews)
0.0