Create Feedback Form

I have a very quick and easy project I need a feedback form that will take about an hour to program. Skills required will be CSS, PHP and CAPTCHA. Following are the instructions. 1. Take a look at the old from here and use it as a guide. [login to view URL] 2. I redesigned the form, added some more input lines and you can see the new template that you will be working with here: [login to view URL] 3. The script part needs to be in PHP. 4. It must be simple. The reason is because I own many domains and will be using the form in lots of places. Therefore, I need it to be flexible so that I can move it around and make changes without it altering the script. A good example of a good form that was done for me is here: [login to view URL] I have changed this thing all kinds of ways and moved it all over the place and it never fails to work. 5. Some of the things I will need to be able to do are: change the name of the file, move it to another domain, place it in different folders or root directory, edit the CSS and all without affecting the workmanship of the script. (ps: I am aware I will need to update the links to captcha if the file is moved). 6. The captcha image part needs to be working. 7. Hopefully it will be simple enough that I could sometimes change the subject line (you have feedback from a visitor) and the "send to" where the information is to be received (information will be provided to the winner). 8. I will provide instructions to ftp my site to the winner 9. When you are done please take the new file ([login to view URL]) and write over the old file ([login to view URL]) so that the link to the good file that you have created is now: [login to view URL] 10. Test, test, test. That's it, you're done!