Contact Form For Website

Contact Form For Website
Hello,
i have a small one-page html website where all menus are linked to external sites. Now i need a contact form which is linked to an internal site – a second page. The form should be emailed to a email-address. I have attach a screen of the form and how it should look.
The form should be based on php and should check for data entry.
It would be great to integrate also a captcha image.

Regards, Chris

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