I am experienced in web application development using php, core java, html5, css3, ajax, jquery, javascript, struts, mysql, wordpress, joomla, postgresql, oracle, j2ee.
I can make that form for you in a day (maybe two if it needs to actually connect to a database). I have studied PHP in the recent past and am now studying JavaScript for about a month or so, so this form should be an easy task for me. Looking forward to working with you.