Two Line Form, post to Data Base

I need a two line form, "Name", and "email Address", verifiable with the "at" symbol, and the "." and something in the name field. The submit posted to a simple data base, on the ftp site, (you supplying the db) one that is sortable by name, and email. Then once verified it will set a "cookie" on their computer, ( an ID cookie, so next time they won't have to fill in the form) and send the user to a url. Then an auto responder, to send a "thank you , for your interest", note. I'll supply the html page for the form and the copy for the "Thank You". and the url where the user will be sent. ## Deliverables Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. Complete copyrights to all work purchased. a simple data base, set up on the ftp site, one that is asscessable and sortable (just show me how). the Id "cookie"? Basically I need it all done and working, and done yesterday. Payment imediately. ## Platform 3.0+ versions of Internet Explorer, and Netscape for Windows 95,98,2000,XP and Mac Os 8.5+