Convert a PDF application form, to an HTML form for web site

I need to convert a PDF application form to an HTML form. There are some requirements: 1) The form table width must be 640 pixels wide (see example) 2) it must contain all fields from the PDF form so that when it gets emailed, all fields are identifiable and can be re-inserted in a blank form by the recipient getting the results. 3) At the end of the form it must have a box to select files from viewers computer, and attach to the completed form. 4) no fields need to be required. 5) need to provide the script to make the form run on a basic Linux based server (can be php, etc.) just tell us in the document where to insert the recipient's email, and any other pertinent info. 6) Turn around time must be 3 days or less. 7) See the sample form we started for you.... you can use that as your basis, or re-design if easier, but the form MUST fit in a 640 pixel wide container which we will be adding to a web page with that limitation. 8) the PDF form to design, and our started HTML document are both attached for your review.