Request/contact form with SMTP authentification HTML/PHP

SMTP authentification PHP form script for simple contact/request form. I need an email contact/request form created for an HTML page ( see attached example). The form needs to be compatible with smart phones and mobile devices, so no flash. Just HTML and PHP with SMTP authentification as my hosting provider doesn't use mail() function anymore. It needs to match the colors and style of the sample form provided - the buttons have already been created and the form should have a transparent background as in the example. Should be complete with a "message sent" confirmation page element, as well as error messages in red for specific fields if they are left blank. I need this done asap, so someone who can do this quickly and easily, and is ready to work now. Max budget is $35.