Simple E-mail Form + Jquery + Php

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This is a very simple and quick project.

I need an email form + Button that records the email and writes it along with the maxmind geoip city of the user into a text file.

The text file should be in this format:

email1:Chicago
email2:New York

I need the form to be positioned in the middle, so I can simpley change the background image behind it and make it appear as a completely different page.
http://i.imgur.com/YwGZV.jpg This should be the background image http://i.imgur.com/hF3rx.jpg shows where the form goes.

The form should have the following features:

– Focus the cursor onload into the form
– The form should be white, with rounded corners, with padding and 25px. The button should be http://www.zurb.com/blog_uploads/0000/0617/buttons-03.html ( first black big one) it should be scaled to match the form size.
– PHP/Jquery email format validation
– Jquery popup alert that fades 2 seconds if the email invalid. Please use http://www.bitsntuts.com/demos/twitter_alert.php and the icon http://cdn1.iconfinder.com/data/icons/function_icon_set/warning_48.png before the text. If the email is invalid, clear the form, and return focus to it
– redirects to page2.php when email valid

It should work in IE6+/Firefox/Safari/Chrome.

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