Hi sir!
I can do this, is very easy for me, because i am stack developer here in Brazil, and this its not a chalange for me.
I only take one project at time, to focus on the project and then delevery a great product for my clients.
I can Negotiate for better price for you.
IDEIA: I can make the user inform the email and name and send to you in same page of the app, and then you can login and see the details and contact the [login to view URL] this?Because the client dont need go to the email and send to you, its more easy form him.
what i gonna use:PHP,javascript.
Thanks for the attention, wait for reply.