Please see attached file.
I need for you to re-create this information into a nice looking, well spaced out, PHP FORM. I will send you one of the pages that you see at [url removed, login to view](dot)com. You'll need to build the form within one of these pages.
Next - we need the form to simply submit to an email address which we will provide you.
You will be given FTP access.
let me know if you have questions.