Need html code to add the following to my website:

Add a Contact Us section to your site:

• Nicely formatted form that requires:
  • First Name
  • Last Name
  • Phone Number
  • State (use a drop down – only need to include NJ, NY, PA, CT)
  • E-mail
  • Date of Birth
• It requests: Error checking for required information
  • Address
  • City
  • Zip
• Error checking for data type, size, and basic format (especially important for date of birth)
• On the form processing page: Echo back the users first and last name.
  • Show today’s date
  • Echo back the visitor’s age in years
  • If the visitor is older than 55 indicate that they are entitled to a senior citizen discount
  • If the visitor is 30-54 years old indicate that they are entitled to a middle aged citizen discount
  • If the visitor is younger than 17 indicate that they are entitle to a youth discount

For example, my results page might be something like:

Ross Malaga thank you for contacting us. Today is May 1, 2014. Since you are 44 years old you are entitled to our middle aged discount.