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form required on a wordpress site

I have a wordpress site and I would like a form added to it.

Attached is the initial graphic. The user inputs the zip code it will show the rest of the form. The rest of the form will have the following fields:

Your Pest Problem: (checkboxes values are: ants, cockroaches, silverfish, spiders, fleas, termites, wasps or bees, mice or rats, mosquitos, other, don't know)

First Name, Last Name, Day Time Number, Cell, Address, City, Zip, What Kind Of Property Do You Have? (radio button options: House, Apartment), Other Information (eg. description of your problem.

Take a look at [url removed, login to view] and enter postcode W1F 7EZ and click go. You will see how the rest of the form becomes visible. I want it like this.

Form should go into an already existing db.

Evner: PHP

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Om arbejdsgiveren:
( 51 bedømmelser ) london, United States

Projekt ID: #3318086

Tildelt til:

alexboka

See private message.

$17 USD på 1 dag
(50 bedømmelser)
4.6

2 freelancere byder i gennemsnit $11 på dette job

kingkashifvw

See private message.

$4.25 USD på 1 dag
(0 bedømmelser)
0.0