Build a Website (only integrating a form)

I have a contact form template (see file I uploaded). I need to add 3 fields. one drop down for regions, one for a contact number and a surname. jquery validation must be extended for the extra fields and also validate email textbox correctly. Form then needs to be made mobile responsive. It must also have functionality inserted to send actual message as rich text format. When the email arrives in my inbox from the form, the 'sent from' email must correspond to the email address the client used on the form. So that I can just click reply. once this is done pictures must be removed. the form must then be inserted into my other webpage located here: [login to view URL] After this the page should also be 100% correct (checked with w3c validator). also the css. Thats all Please give me a good price.