568762 Email Database

I need a database where when a customer comes to the site and fills out the form (attached). The companies that fit the profile are emailed the form that the customers filled out. I will be designing and doing the website and forms. I have done a detailed video of what I need: [login to view URL] Site is built in PHP. I will be filling in the Email (company's) info. It needs to have a form that I can fill in and it will be included in the precise search. The admin where I enter the information, MUST BE FULLY SECURED BY PASSWORD. Let me know if you have questions. All bidders must be punctual via email, skype, and Yahoo IM.