Design a Survey Form

I am looking for a simple survey form built in HTML/PHP. The form should match the branding of [login to view URL] (using #5D83A0 for any color elements) and should be influenced by the wire frame attached. All black text/images should be included in the form. All colored remarks are for information only. The scale ratings should be based on the "Movie Example" at [login to view URL] or something similar. The form should include validation that prevents the form from being submitted without the required information. The action of the form is not in scope, but the form must be written to be able to post data to a handler on our side. The deliverable should include all necessary files to run locally. CDN and remote hosted resources (JS, CSS, etc.) should not be used.