Website Popup Registration Form

We require an experienced PHP developer to make a smart, attractive popup registration form. Needs to be done the soonest possible. Our Website We have a website built in a proprietary CMS that uses PHP elements. We have FTP acces to the site. Project description We want a pop up form that visitors must fill in before watching a video You can use any common programming elements Ajax or jquery or whatever you want. It must perform well in all common current browsers - IE 7 to 11, Chrome, Firefox We want the code to be fast to load. Using the form Triggering the form pop up is typically be from an image on a page. We can then call the form via javascript or whatever you decide is practical. The form is to pop up in an overlay (lightbox) it can be centered on screen no matter what element invokes the form. The form will have a heading title and text area above the fields. These text elements re to be passed as a prameter from the javascript. Form fields to be - name, company, email, phone and comments The fields should be validated (see below) When the user submits the form successfully - email the data to our email PLUS immediately close the form and open a po up (lightbox) to play the video. We would ideally like to be able to pass a parameter to stipulate the size of the video when it opens. eg full screen or fixed size. Typically we use VIMEO. Note: We realise that visitors can read the sourcecode of the page and get the detail - thats OK - this is not secret information it just for lead capture. We want the form to be coloured and styled to compliment our website [login to view URL] Cookie If the visitor has cookies enabled, we would like to store detail of their form entry so they dont have to re-enter each time Plus capture their IP address Plus we want to store time & date stamp a record of each video they view Each time the form script emails us, we want this data at the bottom of the email so we can see a history of what they looked at and when Form validation name to be longer than 3 character company name - no validation email - a valid email format - eg must have "@" and "." in it phone number must be a minimum of 10 numbers with the spaces removed comments to be a 3 line input area - no validation