Get a Freelance Job

I have a contact form (HTML) that I would like to connect to a mySQL database on my server. Once the user submits the form, I need the info to populate the database. I also need an admin page where I can access the information and sort by date, last name, first name…etc. This is a straightforward process if you know what you’re doing. I need this done in less than 3 days. The server is Linux. Please specify the programming language you would use.

1) Help create a database for contacts & email newsletter + provide a way to un-subscribe.

2) A form the visitors fill out needs to send fields directly to a mail account without calling users email prog., plus log the visitors contact info into the database.

3) The form =
First Name (required)
Last Name (required)
Address = Town, State, Country, Zip (required)
email (required) A way to check for bogus email addresses?
Phone (optional)
Description (required)
Attach up to four jpg’s (required) Limit type of file and size.
Subscribe to site updates check box (checked by default)

Limit the number of times a visitor may submit per time frame by comparing visitor log possibly.
Does form need a random code generator with an input verification box?

Would like to feed data from forms on other areas, like sweepstakes, contests and ecommerce eventually.

May need more or less fields depending on input from programmer..

The database structure is already completed.

Script needs to be able to work from an iPhone, Blackberry or other web enabled phone or computer (not a WAP script)

Form 1: Login page. User only needs to enter 1 field (PIN#)

Form 2: User enters in data. Maybe an Ajax type form for 2 of the fields. Pre-filled date, Adds User who created data to the appropriate field in table.

Form 3: A Thank You message that the data was entered correctly.

See PDF Attachment for more information.

This should be a simple project and should be completed in under 2 hours.

Programmer will be selected based on Price and Feedback.