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Email form with automatic reply

I need an email from for my website. It's not too complicated, but this is basically what I need:

1) The form should include the following fields:

1. Name (text field)

2. Email (must be mandatory field), must validate it's a valid email. (text field)

3. Date (it would be nice if some little calendar pops when user clicks on this field, and allows to user to chose a date). (pop up calendar is not required, let me know how much more for this feature).

[url removed, login to view] (text area)

5. Attach file (user can click this button and attach a file to the email to be sent)

6. Additional notes (text area)

2) There should be some sort of CAPTCHA where the user enters the letters in an image in order to avoid spam

3) When the user clicks submit button, user should be redirected to a "Thank you" page within my site.

4) I want the email to be sent to my email address. I'm not sure how you're going to handle sending the email, but if you're script requires my email address and password then that's ok.

5) The script should access my email account and generate a confirmation email letting the user know that his/her request has been received.

Let me know how much this would be.

Thanks.

Tony

Skills: HTML, Javascript

See more: email form reply, email automatic reply form, thank letters, thank email, thanks notes, valid email address, email valid, email address valid, valid email, tony, submit spam email address, nice html form, javascript image handle, html submit file, user enters file name, form image, mandatory text, email image , script form address, website order form script, email address required, generate captcha, html validate, required field javascript, address sending spam

About the Employer:
( 142 reviews ) Chicago, United States

Project ID: #1289508

33 freelancers are bidding on average $91 for this job

sureshdevi

I can create a email form with captcha and automatic reply with your email account. Thanks, Suresh

$80 USD in 1 day
(270 Reviews)
6.6
toinnisfree

pls chk pmb

$135 USD in 2 days
(117 Reviews)
6.6
SigmaVisual

We can help in your project, please check PMB and our ratings/reviews to get idea of our experience.

$100 USD in 3 days
(34 Reviews)
6.2
randdythea

hi sir,please check PMB, thanks ^_^

$90 USD in 3 days
(109 Reviews)
5.8
harishse

Hi, i read the project detail and i can do this asap,,

$80 USD in 1 day
(23 Reviews)
5.3
BitsLogic

Dear Sir, We are interested in working with you. Over the years we have worked on many projects, both large and small. They have varied in complexity from simple reusable modules to enterprise-wide web-enabled applica More

$80 USD in 3 days
(15 Reviews)
5.3
MustafaSR

Hello Tony, Please check the PMB

$90 USD in 2 days
(24 Reviews)
4.9
kultech

I can done. Please check PM and my review.

$80 USD in 2 days
(31 Reviews)
4.9
honeyweb

Ready to Start!Please check your PMB:)For More Info! Thanks Madhu

$80 USD in 1 day
(40 Reviews)
4.8
raodp

check your PMB. thanks

$80 USD in 1 day
(31 Reviews)
4.7
gutenmorgen11

Hi. I'm ready to start. Please check PM.

$80 USD in 1 day
(25 Reviews)
4.4
adasoft

please check your PMB

$80 USD in 3 days
(7 Reviews)
4.2
jagaro

Flash developer at your service

$80 USD in 0 days
(9 Reviews)
4.1
lexcode

please check PMB

$110 USD in 3 days
(10 Reviews)
3.6
vinphpmysql

Ready to start

$125 USD in 1 day
(11 Reviews)
3.6
stefanache

Hello, Please see PMB. Thanks.

$80 USD in 1 day
(7 Reviews)
3.7
rmrf

Hello sir, I'm confident to handle your project. Please see your inbox for more details.

$80 USD in 1 day
(10 Reviews)
3.5
Alfateck

Hello. I am ready to start this little project. Please read my message and get back.

$80 USD in 2 days
(3 Reviews)
3.0
littlemaster2706

Hi!! I am ready with the code output (in ASP / .NET). I can assure you that i can provide you, something more than your expectation in terms of output and build a strong business relationship for future.

$80 USD in 0 days
(3 Reviews)
2.4
formina

Experienced in php forms/spam troubleshoots for 5+ years. this job would take a hour. ready to start. kind regards.

$80 USD in 0 days
(2 Reviews)
1.6