Easy Perl Form to TXT Script

Hello, I hate asking for cheap work but I'm working on an experimental project that I can't spend a lot of time or money on. I'm a flash and web developer and need a perl script to work my project. I noticed there are some people who do stuff really cheap so figured I'd give it a try. Attached is a sample html form, an example description of what should be entered along with detailed description of what I need, and what I need output. I need the data from the form to be written in a certain way to the text file to be loaded as variables into flash. This isn't neccessary as but, it would be a bonus if the coder is VERY experienced in PERL and PHP as I plan to develop a lot of Flash/web apps soon that I'll need scripts for. ## Deliverables I plan to tear it apart, re-write it, and modify as neccessary as the project progresses so, all I need is the script ([login to view URL]). I don't need any installation or anything. ## Platform unix/apache/linux I need to be able to edit the script in Win Notepad