Just need a form made to work properly to submit data to email address. Form and web page is already made out. Just need to have where the form requires certain fields and data can be sent via electronic email. Need someone who can do this very quick (couple of hours max). Must test code to work properly before escrowed payment is made. Will escrow payment directly upon choosing a programmer. Please see attachment for a view of the form. Required Fields need to be First Name, Last Name, Address, and Home Phone Number. Should pop-up a message if those are not filled out if the submit button is clicked without such required fields filled out.
All needs to done via web page code that will be provided ([login to view URL] file) after you are selected. Site will be a leads type site.