You should only do the front-end work. No back-end work is necessary from your part.
NB! This is not a complete site not even a complete page you should only create a small part of a page.
16 freelancers are bidding on average $135 for this job
Do you want Ajax get/post setup on the front end and linking to a php script? I can return the fakes into the fields for you using custom jquery (no external plugin)