Make a page with a form which can be submitted on our Phpbb forum

We consists a website with a Phpbb forum on it and we want to have a page created on the forum where people that are logged in, can submit a form that can be emailed to us or else entered into a database we can privately access (whichever is more cost effective)

The form will have the following fields-

First Name-

Last Name-

Date of Birth (mm/dd/yyyy)-

Address-

Phone Number-

E-Mail Address-

Representative- (Drop down)

Procedure- (Drop down)

Procedure Date (mm/dd/yyyy)-

Before Weight-

After Weight (pounds)-

(All of the above information must be required for submission)

Testimonial field- text area (min. 200 words to max 500 words)

Video Upload (Optional) - So they can submit a video

Before Picture (Required-

After Picture (Required)-

Additional Picture (Optional)-

Desired Skills are MySQL Administration, HTML, PHP, Database Programming