I am looking for someone to design/program a simple page on my website that allows someone to enter information for an online mortgage application. Some fields the customer will type data in, others will be a drop down menu. Some fields must be mandatory, others can be left blank. When they click proceed, all the info is summerized and they are given a chance to review it to send or make changes. If they click submit, all the info is then emailed to me and the customer automatically receives a confirmation email that the data was sent (email address being a mandatory field.)
There are about 60 input fields, with about 10 being mandatory.