Contact Form

I need a form with fill in blanks and drop down menus for a HTML 5 page and that the form is verifiable so that all the options are filled before it can be email back to me. I also need that once the form is submitted it emails to me. I should be able to change the drop down menu, email and questions. I am using Dreamweaver to embed the code I need it on a code base. I need the background to be light transparent grey and text off white: Name:___________ Phone:____________ Email:______________ Date that you want your video to be produced:______________ Which city tour would you like your video to be produced (drop down menu) -South Florida -Las Vegas -LA/Santa Monica -New York Package (drop down menu) -Package A -Package B -Package C -Special Video for: (drop down menu) -Solo -Couple -Group -Other Your budget for this video:________________ Comments:__________________ Send (button)