Online form submit to email via PHP

The attached form should be converted to a webpage form (approximating current layout). The form fields should be submitted to a PHP script (you provide) that will email results to a specific email address that i will provide. Most fields will require validation of input. I suggest the script located here ([login to view URL]) but am open to looking at others if you prefer a different one. I also want to use a system such as re-captcha (or your suggestion) to minimize spam postings. For layout, I am okay with the use of tables in the HTML for layout rather than CSS (assuming this will make the project much easier/faster/cheaper). The server is a shared hosting account at 1&1 with PHP 5. No special modules are available, so this should rely only on features in the base build of PHP...such as mail(). The emailed version of the form should also have "layout" which is another reason that tables are okay. Please contact me with any questions before placing your bid. There is one change to the attached form: Job references will require an email address in addition to other contact info. IMPORTANT NOTES: - I may not wait until the project close to select a provider, so bid early. - Payment will be made only by a final 100% completion "milestone" payment through this website as per the amount of your bid and no additional payment or bonus will be offered. - If you attempt to contact me outside of the Freelancer.com message interface, I will NOT select you for the project. - I will retain rights to everything you provide without attribution and may modify it in the future without contacting you. - I prefer to work with a provider who can show me similar work and/or who demonstrates that they have clearly read the project description. The more relevant detail you provide in your bid, the more likely I am to select you.