PHP Form required

I need someone to make my simple PHP Form work as required I will supply the PHP Form that has been made. I need someone to make the end PHP Form look like the image made, as well as making all of the Fields/Text boxes and drop-down lists required for the complete form. When the form is sent successfully, I would like a 'thank you' message to be displayed saying it has been sent (exact wording will be supplied to winner bidder). I also need the winning bidder to make the page vertically centered. Please only bid on this project if you can get it done quickly. As I am sure you can see, it is a small and quick job that will be paid immediately upon completion. Cheers and good luck