299976 Form-php email plus webdatabas

I need a webpage php form that not onlys sends data back to email of main site, but adds it to a MYSQL database with an web ADMIN interface. ADmin area needs to be able to assign members, passwords etc. Should have logo upload, and nice PRO layout. The form results should be organized by date, last name, first name, address, city, state, zip, other information. The results MUST be available via the webbased MYsql database, in an Easy to read and understand information. Should have option to email clients right from the webpage. The database should include what page they visited, ie. what they are responding too, and all results of that form I need some of the same form on different pages in the website, and some basic different form layouts on other pages. The forms could be geared like so: All forms needs disclaimer built in for * Check this box, you are authorizing us to Contact you by phone and/or email.--small print. This project must have a UP and running DEMO site I can TEST prior to making any payment. The end result of the forms processed must look PROFESSIONAL, and should be easily modified to add logo and change background. Form Script whatever used, HAS to be VERY secure. If you can do this, please post a reply. ------------------------------------------ Your Contact Information (Please complete all fields) First Name: Last Name: Daytime Phone: Evening Phone: Fax: EMail: Street Address: City: State/Province: Zip/Postal Code: Comments: REport selection drop menu box to inquire what FREE report they need. --------------- Another example: Your Contact Information (Please complete all fields) First Name: Last Name: Daytime Phone: Evening Phone: Fax: EMail: Street Address: City: State/Province: Zip/Postal Code: Are you looking to evaluate your homes value for the purposes of selling or refinancing? Selling Refinancing If you are planning to sell your home, will it be within the next 6 months? Yes No Description of the home you wish to sell: Style of Home: (eg. 2 levels, 1 level, bungalow, backsplit, etc.) Type of Home Detached Semi-detached Link Townhouse-Freehold Townhouse-Condo Condo Other Approximate Square Footage: Lot Size: ft. Frontage x ft. Depth Location: Type of Heating: GAS OIL ELECTRIC OTHER Age of Home: Number of Bedrooms: 1 2 3 4 5 More Number of Bathrooms: 11.5 2 2.5 3 3.5 4 More Fireplaces: YES NO MULTIPLE Finished Basement: YES NO No Basement On a scale of 1-10 (with 1 being Poor and 10 being Exceptional), please rate the showability of your home: Poor 1 10 Exceptional Special Features: -------------------------------------------------------------------