In this gig I can create a one page form with your fields and responsive design. This form can be integrated in your page, but if extension is html, it will must change to php. This form also can be integrated into cms like wordpress or joomla, but you will need php code editor for post editor. This form will not store data into database, if you want to store data into database, look gig extra ... If you want me to integrate form code into your wordpress or joomla site, look gig extra ... Job will be sended to you in php file.
Submited information on that form will be sended to your email.