Mobile-friendly HTML registration page for loyalty scheme

General information for the website: Single webpage (under existing branding) that allows a user to register/update details against a loyalty card number on our server (PHP script to POST the data to the database will be provided).
Kind of development: New website from scratch
Num. of web pages/modules: 1
Description of every page/module: We require a HTML/CSS/JavaScript/PHP developer to produce a single, responsive webpage to allow users to enter/update the personal details held against their loyalty cards on our server.

The page must be responsive in that it must render suitably on different iOS/Android smartphone screen sizes.

A high-res logo for the loyalty scheme will be provided. Colours/design of the resulting page must complement this. The page must be of a high quality.

The registration page to be produced will be accessed via a link on the back of the customer's loyalty card in the iOS Wallet and Android equivalent. The passes are already being distributed, so no development work is required in this respect.

If the card number has already been registered then the customer's existing details must be pre-populated on the page, ready for the user to edit. A PHP script/function to retrieve existing details can be provided.

When the form/page is submitted, the details should be posted to a PHP script (which will be provided) to update the details in the back end database.
Description of requirements/features: Details to be captured/updated via the registration page:

Title
First name
Surname
Date of birth
Gender
Address line 1
Address line 2
Address line 3
Address line 4
Postcode
Mobile phone number
Landline number
Extra notes: The person chosen for this project MUST have demonstrable experience with PHP as well as HTML, CSS and JavaScript.