Custom PHP form

We need a simple php form that when submitted builds a URL from the completed form fields, this URL is then shortened using the ‘rebrandly’ (or other) API and then displays the final short URL on the page with a copy to clipboard icon.

The form contains the following fields:

First Name (Input field)
Last Name (Input field)
Amount (Input field)
Reference (Input field)
Siteref (hidden)
Profile (hidden)
Currency (hidden)
Version (hidden)

These need to be combined into a dynamic url which will looks something like:

https://domainname/process/payments/choice?sitereference=test_12345678&stprofile=default&currencyiso3a=GBP&mainamount=400.00&orderreference=C%26G+test&version=2

This URL needs to be submitted to a rebrandly (or other) which is a Bitly type service, the resulting shortened URL will then be displayed on the page similar to below:


https://rebrand.ly/6dqpp50 (PASTE TO CLIPBOARD ICON)

We need someone that can start immediately on this project.