Need Contact form Fixed in Html website -- 2

I need my Contact form exactly how it is in the image attached. Right now i have a blank Contact page. I need this done right now. It should not take you more then an hour to finish this if you know what your doing. How it should work: The user will select what method to send the email 1)If the locally button is selected then once the user fills all the information out and clicks submit it will send that info to outlook. 2)If the Remote button is selected once they fill the form out and click submit it will send the email from the server using php. Need reset button on contact form as well. **** $15 IS MY BUDGET, IF YOU DONT LIKE THAT THEN DONT BID*****