Simple PHP form

I have a few immediate small jobs for a capable, keen and skilled freelancer and then ongoing work if it works out. For now I need a simple PHP form that can be filled in while taking details from customers over the phone, then select an email to send it to from a drop down list. I need you to develop the code and provide it so I can upload it to be used by our employees simultaneously. I am open to advice on how to best use this but was thinking of uploading it to the desktop to double click to open in a browser, I need to be able to test it prior to paying for it. Also needs to work on all platforms. The form will need the following: Enquiry form (title in bold) Taken by: (with box to write in) Customer details section: Contact name: (with box to write in) Company name: (with box to write in) Delivery address: (with box to write in) Mobile for delivery: (with box to write in) Email: (with box to write in) Where did you hear about us? section: (Drop down containing: Google, Referral, Mail out & Other, then underneath the drop down: Notes: (with box to write in)) Main notes for the enquiry section: Notes: (Larger box to write in) Measure & Quote section: Would you be available for a free measure and quote?... (dropdown yes or no), (default to be set to No) If yes: "I will ask <installer> to contact you as soon as possible to arrange a convenient appointment for a measure and quote, <installer> will bring some samples and be able to advise on the best solution for you. I will then email you a quotation..." Assigned installer name: (with box to write in) Then I'll need a separate section to be able to select an email from a dropdown box to send the enquiry form to Then a Cc: dropdown to add a second email to copy in (set to default: admin email) I have attached an example of the printed form that we write on currently but this is just to give you an idea of what we need to improve on. Thank you in advance, Luke