71032 Need a contact form

I need a "contact us" form on a php page. I need the form coded so for each topic they choose it goes to a certain email address assigned to that topic. I also need the script to track the users IP address and print out the date it was submitted in the email. The email addresses in the script have to be decoded somehow so spam scanners wont pick them up simply by visiting the page. Attached is the page, after they click send have a prompt message come up saying “Message Successfully Sent”. If they forgot to answer a required field, have the prompt message say which field is required that they have to fill out that they didn't. Example… “Your email address is required, please fill out this information before sending”. I have also attached a document on how I want the email to appear. I assume this project shouldn't take long to complete and my budget of $10 reflects that. This project needs to be completed within three business days after selected programmer accepts project. If there are any questions, fell free to post a message on the board. Thanks and keep the bids relevant.