Simple Information Gathering Form

I need a form today for gathering a bit of information on my website. I have a "look and feel" that I want and I want the form to collect 5 pieces of information and personal information from the customer. This information must be saved in mysql and have a basic admin function to access and edit that information. Look at this form:"[login to view URL]; This is the "look and feel" that I want. This job must be completed today, ASAP. Address any questions immediately. Thx