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Simple PHP form - Repost - open to bidding

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: HTML5, Java, Javascript, jQuery / Prototype, PHP

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About the Employer:
( 0 reviews ) India

Project ID: #8954176

11 freelancers are bidding on average $28 for this job

digidreamstech

Dear Luke, Need PHP Form Only...? We will do it. Check the requirement you mentioned for Form. Please analysis our contour and plan portfolio at afterward freelancer.com url https://www.freelancer.com/u/digidreams More

$30 USD in 1 day
(42 Reviews)
5.8
Projectssss

• Responsive Design with advance level language technology. • Very strong for web based applications from PSD to complete development. • Responsible for working on Front end collaboration with the team and client dir More

$25 USD in 1 day
(18 Reviews)
5.2
JRB28

Working as a full time freelancer. Available Timings 11.30 AM to 9.00 PM IST Monday to Friday. Technical Skills - 7+ years of experience in web development - Web Front End experience (HTML, CSS & JavaScript) More

$30 USD in 1 day
(3 Reviews)
3.4
ruizramosjose

I have some codes that already does something similar that you want. So my developing would be fast and efficient. I would be a good choice for this project.

$30 USD in 1 day
(5 Reviews)
3.5
libsco

Hi, It is a simple job. I can do it according to the requirements and in the time limit. I have done a large project LMS(Visit my portfolio) with a lot of forms and very advanced things. MP me to discuss more about tha More

$11 USD in 1 day
(4 Reviews)
2.4
byvdigital

Lets Start! I have a awesome team to get it done in 24 hours. We have been doing projects on Upwork since last 2 years. New on Freelancers but know what we do best. Looking forward for working with you. I have More

$35 USD in 1 day
(0 Reviews)
0.0
bufferking

i can make this form for you using html and php as i have expertise in php i will make a form using html or bootstrap respsonsive form and connect with php to a database and if someone fills the form you can see that i More

$20 USD in 1 day
(0 Reviews)
0.0
uguismaris

I have successfully integrate a website using PHP and other web programming language. You may visit my portfolio for more details.

$25 USD in 1 day
(0 Reviews)
0.0
sibtay003

I can do it its very simple.I will do it Quality-wise up to the [login to view URL] i couldn't maintain a quality i will not take any amount of this [login to view URL] You

$27 USD in 2 days
(0 Reviews)
0.0
nmacfarlane

Hi, for $50 I can design the form you need, with all the required inputs and also with a cc function for emailing to two people at once. I will also explain proper deployment of the form for employees to use, as php More

$50 USD in 1 day
(0 Reviews)
0.0
zambadamit

A proposal has not yet been provided

$30 USD in 2 days
(0 Reviews)
0.0
balaprathigadapa

A proposal has not yet been provided

$25 USD in 1 day
(0 Reviews)
0.0
sandeepsoni2291

A proposal has not yet been provided

$25 USD in 1 day
(0 Reviews)
0.0