Create a Contact Form

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)


Date of Birth

It requests:




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.


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: Graphic Design, HTML, PHP, Website Design

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

Project ID: #1237689

3 freelancers are bidding on average $250 for this job


I can do this. Please check PMB for further details.

$250 USD in 0 days
(242 Reviews)

ready for service sir, thanks.

$250 USD in 1 day
(79 Reviews)

Dear sir, I could finish it in half an hour. I am ready to do it now. Please see PM for more details. Thanks.

$250 USD in 1 day
(2 Reviews)