Simple PHP form

I have a few immediate small jobs for a capable, keen and skilled freelancer and then ongoing work if it works out. For now I need a simple PHP form that can be filled in while taking details from customers over the phone, then select an email to send it to from a drop down list.

I need you to develop the code and provide it so I can upload it to be used by our employees simultaneously. I am open to advice on how to best use this but was thinking of uploading it to the desktop to double click to open in a browser, I need to be able to test it prior to paying for it. Also needs to work on all platforms.

The form will need the following:

Enquiry form (title in bold)

Taken by: (with box to write in)

Customer details section:

Contact name: (with box to write in)

Company name: (with box to write in)

Delivery address: (with box to write in)

Mobile for delivery: (with box to write in)

Email: (with box to write in)

Where did you hear about us? section: (Drop down containing: Google, Referral, Mail out & Other, then underneath the drop down: Notes: (with box to write in))

Main notes for the enquiry section:

Notes: (Larger box to write in)

Measure & Quote section:

Would you be available for a free measure and quote?... (dropdown yes or no), (default to be set to No)

If yes: "I will ask <installer> to contact you as soon as possible to arrange a convenient appointment for a measure and quote, <installer> will bring some samples and be able to advise on the best solution for you. I will then email you a quotation..."

Assigned installer name: (with box to write in)

Then I'll need a separate section to be able to select an email from a dropdown box to send the enquiry form to

Then a Cc: dropdown to add a second email to copy in (set to default: admin email)

I have attached an example of the printed form that we write on currently but this is just to give you an idea of what we need to improve on. Thank you in advance, Luke

Skills: HTML, PHP

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About the Employer:
( 9 reviews ) Sandgate, Australia

Project ID: #8735123

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Hi, We will give you all professional work, you will be satisfy with us, we will give you good support after project done, we are online all the time and contact us any time. our price also not very high we will charge More

$29 AUD in 1 day
(32 Reviews)

30 freelancers are bidding on average $36 for this job


Hello! With 98% to 99% completion rate, 850+ successfully completed projects, and a 5.00 reputation (maximum possible, 5.0) (Yes, not even 4.99 average rating, can be verified on my profile page [login to view URL] More

$126 AUD in 1 day
(654 Reviews)

Hi, I am sajjad a web/PHP developer and i can do your job right now just send me the required details so we can start the work immediately. Regards

$32 AUD in 1 day
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Dear Client Greetings, Hopefully you are doing well. I have working experience of more than 6 years in Web Site design & development and have developed more than 200 websites here on & more than 150 More

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Hello Sir, I myself a website designer having a team of experienced designers/ writers/ developers who will work on your project to complete it as per your requirement. You can check my design portfolio on Freelancer. More

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(48 Reviews)

Dear Hiring Manager, How are you? I am able to do this work.I have more then 3 years of experience in PHP,html. IF you like then i am ready to show you demo of system before award me the project. I More

$35 AUD in 0 days
(73 Reviews)

A proposal has not yet been provided

$25 AUD in 1 day
(23 Reviews)

Hi, I build similar forms before. I'm ready yo help you on this project. If you are really interested to award it, then please reply. I wait for your message.

$35 AUD in 1 day
(76 Reviews)

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$30 AUD in 1 day
(52 Reviews)

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$30 AUD in 1 day
(4 Reviews)

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$30 AUD in 1 day
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Hello Friend I am ready to start right now I have read your project very carefully and I understand what you want. thanks for good and clear explanation I have almost done many work like this. I have very good More

$100 AUD in 2 days
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Hello, I have taken a detailed look at the job specifications. I have well experience in this field of 7+ years. Here are few of my recent HTML + Mobile Responsive Websites Projects: Wordpress website in 2 More

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Hi, I've read your offer for the PHP form and the whole form seems very easy to be implemented, but I got one question regarding the data submitted through the form: Should the data be persisted in some way, for More

$35 AUD in 2 days
(1 Review)

Hi! I'm a software engineer with very good skills in PHP and MySQL. For this task, I'd recommend you to use a web app (then employees will only need a web browser and could type the link you'll provide them) connected More

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