Add a form Submit nicely to HTML page

site: <[login to view URL]> we need to add this form below to page I can set DB PHP/mysql for submission that is our envrionment I want someone to add a nice from like this to page and send me an email when someone register and provide basic CMS with modify/approve records with pagination and status Active, Pending, Inactive for each record of client that was entered with login to admin i WILL SEt db FOR YOU AND OFCOURSE EMAIL CONFIRMATION FOR CLIENT MESSAGE ON SIGNUP AND FOR ADMIN(ME) i WANT TO BE ABLE MODIFY iNFO AND all fields below in the cms and approve them after they are created in pending stratus and approve manually also add special Notes field in DB your bid should include addition of 3-4 fields in DB for that table and CMS functionality for those if needed Sign Up Form: Client Name: Works Comp Patient __ PI Patients \_\_\_|\\_\_\_|\_ Both Address Phone Email: Unlimited Transports Monthly Service Agreement($2000/Month) \_\_\_|\_\_ Bill me Per Transport($20 Per Transport Less Than 80 Miles/ $40 Over 80 Miles) \_\_\_|\\_\__| Special Instructions if any: Signup Now Thx! P.s I will send you HTML and DB info and FTP for site