Hello,
Hope you're doing well, allow me to get right into it.
We can create a simple PHP script which will hold ALL the necessary code (HTML/JS/CSS and PHP) to get a good looking and functional form that'll get the job done.
This shouldn't take more than an hour or two to finish, starting now.
I know what I'm doing and I'm good at it, this is an easy task and you don't have to worry about the payment until I deliver everything.
Thanks for reading,
Looking forward to hearing from you,
Mario Adabachy.