Need a php contact form please?

Add a Contact Us section to My Site:


First Name

Last Name

Phone Number

State (use a drop down - only need to include NJ, NY, PA, CT)


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)

On the form processing page:

Show today's date

Echo back the visitor's age in years

If the visitor is older than 55 indicate that they are entitled to a senior citizen discount

If the visitor is 30-54 years old indicate that they are entitled to a middle aged citizen discount

If the visitor is younger than 17 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:

Mark Hu thank you for contacting us. Today is May 12, 2012. Since you are 64 years old you are entitled to our middle aged discount.

Zip all files and please

Form present and nicely formatted

Required elements enforced

Error checking applied and working correctly

Processed form displays user name

Processed form displays today's date

Processed form displays appropriate response

Skills: Graphic Design, HTML, PHP, Website Design

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About the Employer:
( 0 reviews ) United States

Project ID: #2564055

9 freelancers are bidding on average $36 for this job


Let me done it for you

$35 USD in 1 day
(166 Reviews)

My bid includes Spam protection, if you don't have spam protection and a bot finds your contact form you're going to get a lot of fake submits unless your contact form is hidden from the search engines.

$34.99 USD in 1 day
(66 Reviews)

Hi, I am interested in your form project. Please provide the link to the current site so we can match the current styling. Looking forward hearing from you soon.

$50 USD in 0 days
(45 Reviews)

........... Give you the service beyond your expectations.......... . Thanks.

$35 USD in 1 day
(49 Reviews)

Ready to start and deliver this now.

$35 USD in 0 days
(76 Reviews)

hi Sir! Please read PM. Thanks!

$45 USD in 0 days
(7 Reviews)

Let me do it for you!

$30 USD in 1 day
(0 Reviews)

Hey I can create your contact form with all requirements immediately. Check your PMB.

$30 USD in 0 days
(1 Review)

This would be a very easy project for me and could be completed as soon as you accept my bid.

$30 USD in 0 days
(0 Reviews)

I invite you to work together for this project. I bid with the lowest price I can do for you, to build my reputation on freelancer as a freelancer and not as an employer this time :)

$30 USD in 1 day
(0 Reviews)