I require a custom contact form that will sit on a Linux web server on its own domain.
This contact form will have an address lookup integrated into it.
This is the address lookup: http://www.craftyclicks.co.uk/paf-
This is the code examples for it: http://www.craftyclicks.co.uk/web-
Once the user has found the correct address the contact form will capture the following fields;
Title: drop down
First Name: text field
Last Name: text field
Landline: text field
Mobile: text field
Appointment time: text field with AM or PM drop down
Appointment day: calendar
Enquiry for: text field
Comment: text box
User: drop down
Employee: drop down
Any field that is a drop down must be editable by me.
I must also be able to add or remove fields by either admin backend or via the source code. If it is via the source code you must write a short description on how to do it.
The contact form will e-mail this information once submitted.
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