Need a php page with a form - repost

Hello freelancers, I need a webpage like this [login to view URL] , use any design that you want, but it should look nice and should be relevant to [login to view URL] , for which I need this page. The form and everything else will remain same, I mean the option that it has. You can change the layout as you like it, but it should be classy in looks. I need this in PHP and mySQL. Please note that, this website ([login to view URL]) is made in prestashop, and you will have to work accordingly with the form. I will give you the access to the database. Also, please verify the database structure before starting, as it might be the case that we have to insert the values from this form to multiple tables, that you will have to check out in the database structure. Please mention "Apple" as the first word of your proposal, so that I can be sure that you have read this description very well. I can provide the design as well, but I would prefer that you come up with some designs or templates. Only the persons with relevant skills should apply, else I will reject your bid. All the best.. Thanks Varun