Request Form and Flash Edit

I am looking for a programmer to assist me with creating an online Form that contains text boxes and drop down fields that can be submitted to a specific email address.? There will also be some minor? graphical editing to a picture that we would like to include into the header of the page.? This Online form will contain the following leads What Game would you like to attend?? drop Down field How Many Tickets? Text Box Event Type: Drop Down Field Special Requests: Text box with 500 characters First name: Text Box *Required Field Last Name: Text Box *Required Field Company: Text box Phone: Text Box *Required Field Email: Text Box *Required Field Preferred Benue: Drop Down Field ## Deliverables For now we are looking to create this online? form? that will allow us to capture information from visitors that go to our site.? I have a nice jpg that I would like to work into the header of the landing page but this is not crucial.? This smaller project will be leading into a larger project as soon as we generate some cash flow.