Wordpress Insurance Quote Form Set Up and Posting

Modify a existing WordPress site with new template. 3 pages: Homepage, quote page, and results page need to be created. Requirements: (1) Modify the existing WordPress template to match look and feel of mock ups (changes on header, navigation tabs, body, and footer). I'll send you the original template. (2) Homepage and Quote page. Add an UI interface (e.g. [login to view URL]) to allow users to submit the following fields (below is an example, not the final ones) on the homepage and the quote page: - Name - zip - type - email - birthdate - gender, etc. (2) Results page. Create a WordPress page that displays the results in a matrix (e.g. [login to view URL]). Results are based on the user input filtered by a set of predefined data from a spreadsheet. The user information will need to be stored my SQL database on my server. (3) Automatically posted via xml to and redirect to quote forms on roughly 12 affiliate sites. I'll send you integration documents for some of the insurance providers. Some of them don't have it so you will need to pass through to their html forms. (4) Must support Firefox, Chrome, Internet Explorer, Safari (5) WordPress template must be built and tested on WordPress 3.4.1 (6) You'll need to create and host a demo site where I can validate that all the requirements have been met. After all functionality has been verified and tested, you will need to give me all the WordPress template files and any other relevant files (e.g. mySQL schema, WordPress config files, etc). You'll need to be available to help troubleshoot any problems that I encounter in getting it set up on my side. After you have fully completed the requirements from the mock up as well as I can successfully get these files working on my server, then I will execute payment.