PHP script to write form to database

Have a form on a document which needs to be converted into a plain HTML form which has a script to submit data to a database table. There is also a field needed to upload an image within the form. Will be looking for some very simple jQuery form validation on the page as well. We have no mySQL table ready for this, the developer will need to provide the HTML form, PHP script and the SQL file to generate the table. Approx 40 fields in form, need it done very quickly.