small php application for website

must be done in PHP. Need an application that shows up on a webpage as an information request form such as this one on my site: <[login to view URL]> Requirements: There needs to be an admin interface where I can add a new company when I need to. Also, tracking number of submissions to each company. Also, need ability to put this on other websites and keep track of how many times it was filled out on each site. Also, each site who displays it should be able to login and track their number of forms filled out. Each time a form is filled out this happens. An email is sent to each company individually and an email is sent to admin (me) and if it's from another site an email is also sent to that site letting them know it was filled out there...BUT each company cannot know it was sent to another company. I will be paying each site a per application fee and charging each company every time they get a lead filled out. This is why I need to be able to track stats. More details available but that is the gist of it. ## Deliverables 1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. 2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables): a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment. b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request. 3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement). ## Platform linux server and php....