Create a html/php form for a lead generation page

Please see the mockup for the domain name and what we are looking for. The layout and css are all in place, so this is just modifying an existing template. I would like the page to take in the information hat the user enters, and place it into a MySQL database. The form will error check the entries, making sure that all required information is entered, if required information is not entered then the page will return the user to the data entry page with the field names that need to be filled out showed in red. Upon successful completion the page will place the data into a MySql database with rows of similar names for the data. Once that is done, the user will be sent to a 'success' page that is the same page as the [login to view URL] page, but without the data entry fields. In place of where all of the data entry fields were there will be a success message. That notifies the user that their data has been submitted. An e-mail will then be sent to the the user, using their e-mail they just entered, that requests verification. They will get a link that they have to click that will change their status in the database from 'unverified' to verified'. This isn't very hard or time consuming, so the budget is $50 to $100. Any companies that attempt to place a bid outside of this range will be ignored. You will be given full cPanel access as there is nothing of any major importance running on this development server. Do what you need to do to reach all of the requirements of this project. I look forward to working with you, now and on other projects moving forward. Thank you for your time and attention.