Contact Form Jquery Popup

We need a developer to design a jquery popup contact form using PHP, JAVA, etc which we will need to be able to modify and tweak some fileds ourselves (we have basic knowledge of php).

Submit form must have the following:

Ability for admin to add/remove fields using true/false statements
Custom fields required:

1.text fields
2.check box
3.radio button
4.drop down box

Email validator/checker (to ensure user has entered a valid email address)

Redirect to URL if user’s javascript is disabled on browser
Browser/Javascript compatibility

User must stay on same form when they submit, a successful sent message to confirm

Contact form must have url link to home page after customer submits
Spam protection – Ability to enable/disable captcha

Tick box to allow customer receive a copy of the message

Please see attachment for a direct link to the form we have on our current site.