Need Php Form Edited

Need Php Form Edited
I have a current form that allows the user to enter information and upload a picture. I need the form fields edited and I need when they submit the form instead of going to paypal it will just email the information and pictures to an email address and return to a page.

Change company name to “Full Name”
remove business category
change county network to “which state would you like to block”
remove add text
remove membership selection
add 2 additional upload features so they can upload a total of 3 pictures.
add a check box and say “I require a FREE web camera”
change the check box to continue text to say “By checking this box I agree I am of legal age of 18 years old or older. I understand that I must provide a state ID to prove legal age.”

must be completed whith in 1 day of acceptance or a full refund will be provided.

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