Need a php form by Saturday

I need php form within the next 2 days and thought I’d check to see if you anyone was interested. Here is the information on the form:

It should include the following fields:

Name
Address (optional) (and include city, state, and zip code)
Email
Quantity of dvds (drop-down list for quantity - options 1, 2, 3, 4, 5).

Name and email should be required fields. The results of the form should be sent to my address and a confirmation email needs to be sent to the person filling out the form. The form should be safe and not hackable or exploitable. I will add all the graphics, all I need you to do is the coding of the form. I’m looking to spend no more than $50 on the form. I need the form by tomorrow or Saturday at the latest.
Thanks,

Rusty