Looking for a developer to create a form

I am looking for a developer who can develop a quote form for me. I have got a html design. Just need to develop in PHP, JS and make database for that also. You may need to change the layout of the form. I have only minimum budget for that. I can only pay fix price. I select £50 fix price, because I can't select less then that. If you can't do just leave it. Don't wash your and my time also. Here is a screen shot for that form.