Please ignore the $250 above, you set the budget for $250-750 but I see your $50 budget and will do it for $45.
I can code this script for your site using a variety of techniques depending on what you have available to work with on your web server. I can have the data sent to any number of email addresses and store it in a database if you wish.
I can also include JavaScript validation to ensure they don't leave any fields blank or with incorrect information, and work with you to customize it to your tastes. I work very quickly and efficiently, and can begin work as soon we are in contact.