very simple php project...maybe the simpliest of all

This is a very simple project and i am putting it since i really dont have time.. Here is the details :- 1. There will be a simple form...sort of "contact us" form. 2. The form will have the following fields.."name" "age" "message" and "dealerID" and a "submit" button. 3. "name" "age" and "message" and "dealerID" will be a combobox. 4. This "dealerID" will be populated from the mysql database...(details of the tablename given below this) at the time the page loads. The mysql database will just have a single table..name it anything you [login to view URL] table will have two fields namely "dealerID" and "email". DealerID will have integer value and "email" will have "text". now let us come back to the form. When someone choosed the "dealerID" from the combobox and hits the submit button...the contents of the form should be mailed to the corrosponding email address of the "dealerID".. Thats all... The budget is 20 - 40 USD. I am myself a coder...so dont put astronomical bids...i know very well how much this can cost. The selected bidder has to complete this within 1 day or maybe less.. payments ONLY GAF escrow. I will also take care of the fees which GAF takes incase the bidder is not a gold member. Thank you for reading