Create responsive form from sample, add info to database. Pull reports

What I need you to do is: 1. Create a form starting from this sample. I need the exact same data. [login to view URL] I'll provide you the logo and the colors. It does not need to look exactly like the origininal. Just have the same content. 2. Make sure that the form is 100% responsive and validate data (specially dates and emails). 3. Send the data to a database. I can create the database for you and give you the fields with datatypes. 4. Create an "admin" area, (preferably a folder in the server that has a unique password for all users), where you display: a) A List of the fields in the database, Showing LastName, Name, Email, Date the form was submitted. b) When admin clicks on a name of the list, it will display the full data that was input by the client. Please add option to go back to list or log off. No data edition required. Please, ask any questions you want. No copyright infringement will occur since the target site is also owned by me. In your reply to this project let me know: 1. Time Frame 2. Quote 3. Resources you require.