I need one php webpage designed

Very simply I need one php webpage designed where people can submit their name and email address for a contest to win $100 gift card to my site www.mens-watches.co You will find that my logo attached below. any other art work you might need is on my site. The web form must email the name (first and last) and email address to my site's main email address customerservice@mens-watches.co

The terms and conditions must be listed on the page and they are as follows.

Terms and Conditions:
1. No Purchase Necessary
2. Void where prohibited
3. Gift card delivered electorincally via email.
4. Contest enteries open from 4/1/13 to 3/30/13
5. drawing will be held 5/1/13
6. By subnitting your name and email address, you are agreeing to be added to Mens-Watches.co's email newsletter and promotions list, and you understand that you can asked to be removed at anytime.
7. By submitting your name and email address, you agree to let Mens-Watches.co use your name in promotions to annouce the contest winner.
8. Only one prize per contest period.
9. Odds of winning depend on the number on entries