Creating Functioning Web Form

I would like the attached web-form to submit all results to the following email addresses info at [login to view URL] and sales at [login to view URL], the information submitted via email should be clear and concise. I also would like a database created via access that also submits and logs this information, the database will need to be created in order to submit this information All emails received should have the subject line: [login to view URL] SUBSCRIBER Data in Email: First Name* Last Name* Daytime Phone* Evening Phone Address* Address 2 City* State* Zip* Email* Date of Birth* What dosage of Vioxx were you prescribed daily?* During what period of time was Vioxx prescribed?* Start: End: What is the best way to reach you? Please provide the best place, time, and method for contacting you.* Have you or a loved one experienced:* Please describe in detail the side effects experienced on Vioxx.* ## Deliverables 1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. 2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables): a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment. b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request. 3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement). * * *This broadcast message was sent to all bidders on Monday Dec 27, 2004 3:31:01 PM: would like the attached web-form to submit all results to the following email addresses info at [login to view URL] and sales at [login to view URL], the information submitted via email should be clear and concise. I also would like a database created via access that also submits and logs this information, the database will need to be created in order to submit this information All emails received should have the subject line: [login to view URL] SUBSCRIBER Data in Email: First Name* Last Name* Daytime Phone* Evening Phone Address* Address 2 City* State* Zip* Email* Date of Birth* What dosage of Vioxx were you prescribed daily?* During what period of time was Vioxx prescribed?* Start: End: What is the best way to reach you? Please provide the best place, time, and method for contacting you.* Have you or a loved one experienced:* Please descri be in detail the side effects experienced on Vioxx.* ## Platform Windows