I am in need of a web-based agreement form where the visitor can enter their contact info (most of which will be required), check several boxes to sign up for classes (and enter dates), read through agreement, check "I agree" box and submit the form by email. The information is then emailed back to me, preferably in HTML email format/layout. Use of HTML/CSS/PHP is preferred. The code will be used on an already designed HTML website.
Please see attached image to get an idea of how the form should look like.
Pre-pay is 50%. If you're interested in this project, please provide a portfolio of past work relating to the topic - contact and web-based forms.