Hi! Is this to be a standalone form or would you like it added to another form somewhere? Do you have an existing CSS for this or is that not required?
I could do the work within a day of awarding, allowing for feedback and alterations.
I have developed a whole load of forms during my time working for the yacht company, mostly booking forms but all kinds of searches too, including jquery date entry etc.
I will attach some info about me.
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Website Applications Developer - PHP/MySQL / HTML/CSS/JQuery/AJAX/JS / SEO - 10 years experience building front-end and back-end for a global yacht charter company. I was the sole developer for 90% of that time. I also built my own online yahtzee (dice game) community with real-time games/chat which is still fairly popular today.
Some of the projects I have completed: booking systems, search/sales/accounts/management/CMS tools, file upload handling, image processing (sizes, adding text, grafting two images etc etc), on-the-fly PDF creation, automated emails with files attached, web-scraping (with/without login spoofing), email scraping, financial/accounts calculations/reports, complex management reporting, proposal creator, editing responsive designs, real-time chat and AJAX-based games, community forum, paypal API, google maps, calculators, etc etc.