PHP/MySql - need quick form for website

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Job Description

Need someone to build a new web form (see attached).
- The form will need to be validated (required fields) in the browser, and at the server before user can successfully submit.
- When the form is submitted, it will insert into the database and send an email.
- The email sent will need to be made into a table (HTML email) for easy reading.

See attachment for desired layout.

Upon hire, we will provide web/FTP account and database connection info.

Open Attachment