Small Job, money involved

Looking for a PHP Contact form, I will pay 5$ dollars (Negotiable).

I need it in the following format:

Name:
Price Range:
Your Email:
Job Description: (Drop Down with 30+ options, PM/IM/Post in here for details)
Comments:

Also need an option for Multiple/Other, like another comment box, but only loads if checked.

Please contact me via AIM at Rossperotisapimp.