Css Form + Php Script

Css Form + Php Script
Please take a look at the attached picture. I want a form created and styled with css that looks exactly like the picture. With the form elements and all.

I have attached the color that I want the form created in on the picture. The following things are required:
– PHP processing script for the form.
– Validation for required fields so if they forget to fill it in they are notified on the same page some sort of way with ajax or javascript (highlighted fields that are missing is preferred).
– Email field checked for correct email validation
– Ability for them to be able to upload a file and send it to me.
– Captcha addition feature
– Submit & Reset Form Buttons

Please don’t bid if you don’t know how to do this. I have too many programmers bid that do not have the required skill sets that I have asked for. This shouldn’t take forever. Don’t waste my time or yours with long drawn out overprices bids they will just be ignored. Please type “CSS Form” in your response so I know that you have read the complete requirements. Thanks for your time and attention to detail.

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