Email Form similar to groupon

I need a form to collect email address similar to [url removed, login to view]

I have attached some screenshots.

After hitting submit user is sent to the current days local deal page.

I want to collect all info on one simple page instead of 2 steps.

Only info I need to collect is email address and a city which will be selected from a drop box just like groupon example.

current cities needed are - New York City, Boston, Los Angeles, Westchester County.

I need the ability to add more cities to the drop down box on my own. This needs to be easy to modify and work with.

This needs to be done in php and I must have the ability to easily add to my website.

I need to completed forms to be sent via email to me.

Evner: Grafisk Design, HTML, PHP, Web Design

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Om arbejdsgiveren:
( 24 bedømmelser ) Briarcliff Manor, United States

Projekt ID: #982240

Tildelt til:


Hi, how are you? Please, see PM.

$200 USD in 0 dage
(77 bedømmelser)

5 freelancers are bidding on average $152 for this job


Let's discuss in pm.Thanks.

$150 USD in 0 dage
(56 bedømmelser)

It's good to be first :) Please read my PM. Thank You.

$60 USD in 0 dage
(5 bedømmelser)

hello, i m interested. please check your private message box. thanks

$250 USD på 1 dag
(9 bedømmelser)

Can do the job.

$100 USD in 3 dage
(1 bedømmelse)