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Need a PHP form built

I need to get this form rebuilt in PHP, with the information validating correctly.

[url removed, login to view]

Færdigheder: Javascript, PHP

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Om arbejdsgiveren:
( 30 bedømmelser ) Jacksonville, United States

Projekt-ID: #971116

3 freelancere byder i gennemsnit $33 for dette job

jqMike

I can create the form. Please contact me to discuss details.

$100 USD på 1 dag
(78 bedømmelser)
7.2
bdlancer09

Can do it right now.

$30 USD på 1 dag
(48 bedømmelser)
4.7
gafhus

Ready to start.

$40 USD på 1 dag
(9 bedømmelser)
3.7
mithunmit

hi ready to start.

$30 USD på 1 dag
(0 bedømmelser)
0.0