Create contact quote form

Create contact quote form

Closed - This job posting has been filled and work has been completed.

Job Description

I need someone to create 1 editable quote form for multiple websites.

- Information we need from quote form are

- Name, Number, Email
- Year Make and Model of Car
- Operable or Inoperable
- add multiple vehicle option
- Origin City State and Zip code
- Delivery City State and Zip code
- Estimated Shipping Date


We would like the zip code typed in to automatically fill in city and state

We would like the auto populate make and model of cars while customer is typing: (we can provide all databases for zip codes and cars)

We would like a calendar for the customer to choose shipping date

Once all data is received we would like to forward the data to as many as 10 different email addresses. And the ability to send an email to the participant.

We would like the code to be customizable if we have to change fonts or layout and size.

Simular websites to give you an idea are as follows,

http://www.statefarm.com/discount-double-check/?Keyword=auto%20insurance%20quotes&MatchType=p&Placement=&k_clickid=6996c6cf-5455-efa9-2213-000007a58d68

http://www.quotelab.com/?_xai=23270375492;CQ0-3n1teJDpzIT3DJe2Z2yJPzTePYpC7_rkds879xa382jXMQAGujsJRsmGoT-VpBLYVbpb

http://www.usautoinsurancenow.com/welcome?id=181385316&creativeid=25823892460&adpos=1s4&matchtype=e&network=g&mobile=&placement=&target=&aceid=&apxkwid=1022164

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