Create Web form for e-mailing multiple recipients

I need a form-to-email type page created that's fairly simple except the user needs to be able to choose from a list of possible recipients which ones should receive the information from the completed form (and any attachments that were included). See the attached description. I don't know how hard that requirement makes the request, so I'm posting as a simple project. Please bid appropriately in any case. While price is always important, I'll be choosing the bidder based on the specific information they provide about my project and how confident that makes me that they truly understand the project and can complete it successfully. I need a professional job done, both in the design of the form/page itself (including minor graphics and page design) and the programming behind the form to do the editing and e-mailing.