Simple File Upload

To create a page that can be used in an iframe and also just the code that can be simply placed inside a html page somewhere with html. The page to have the following text inputs (Name, Telephone, email address, Notes) (All single line apart from notes being a few lines) (maybe some notes on how if needed in future to add another single line text input) Then below this the file upload area to have a few spaced to click to add images and the option to add extra lines. (files accepted are image files, pdf and .zip) On file upload the image should be stored inside a folder (folder name can be Name Date and Time of upload and maybe if possible the email address not sure how you can do this with the @ symbol) inside the folder have the image and a some sort of text or html file with the text field details that were entered and some sort of email notification including the text entered and a link to the uploaded file/folder. Please see attached image for example that I want bar the changes of the text inputs. The big one... The program is to work across all major browsers being OLD and NEW Internet Explorer, OLD and NEW Firefox, Chrome etc. If a mix of both flash and java or php is used you can use some switching technique with looking at the browser version and then selecting flash or java etc etc. I want any information thats needed to move from one location to another, I can give ftp access to a folder etc, would preferably want to see it working on your ftp or this ftp then you give help or notes how to move it to a new location etc. Please see this web page for the example program I basically want to copy exactly with some text changes but the uploader to be the same, Also would prefer the colour of the pink in the example changeable via a setting that I can change ie .css or html or something originally I want this red. I don't mind any use of free programs copied programs etc but it needs to work across multi browsers (if not able to show progress of upload using a simple spinning .gif or please wait method is fine the uploader is to be simple and easy to use) and needs to be secure on the server. Many Thanks