PHP Script For Website

Hi I am needing some simple html/php work done. Here is what I am looking for. I am wanting to create a replicated website like the one seen here. I am not looking for the web design really but the coding to make it replicated. I have the design for it already. <[login to view URL]> If you look at the end of the url you will see a unique ID that says "89283". I am wanting to create something like this where I will have a page that all someone has to do is fill in some information and they will get a page just like this with their own unique information after they hit submit. If you scroll down the page, you can see where a person's name, email and phone is inserted down the page. In this case it is: Anne Ahira **webmaster at [login to view URL]** **![][1]+62 81 320.688.898** Also, on the form page, I want one of the options to have a place to add their autoresponder form code so they will get any leads that come to the site. Just so this makes sense... A person will go to a webpage where they see a form asking for the following information: **Name Email Phone Country Autoresponder email code for email follow up system.** When the person hits submit, a person will get a page just like you see above that has THEIR information on it. The autoresponder code is just a piece of javascript they will have that uses their autoresponder email system. Please ask me any questions that you would like. Thanks Dave ## Deliverables 1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. 2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables): a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment. b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request. 3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement). ## Platform windows