Simple 1 Page Website with Mailer Form and Admin Panel

I am looking for a simple website with a form in which a customer can fill in their details, and it sends a formatted copy to the website owner, and the customer via e-mail. It also requires a simple backend panel in which the user can see who has sent an e-mail, and remove them if they're fraudulent. So basic editing. Also a simple notes field to which the owner can add after following up a phone call. Also the form must have an opt-out button in which if the user clicks, they don't go into the 'opt-in' list. This should be downloadable as a CSV for usage with bulk mailers. This is NOT a bulk mailing application, simply for liaising with the customer. The front end form needs to be validated, for e-mail, UK mobile/landline numbers, not allow empty fields. The HTML & CSS can be very simple as this will be styled as appropriate. So this is not about design, mainly functionality and flexibility. I would like this application building in CodeIgniter, and if you understand bootstrap, then maybe use the basic grid to base set up from there. It is a pretty simple product to which I require a developer who is pretty self proficient in their skillset to fully understand what I am going for, however I do have full communication via telephone, e-mail and skype etc, should you want to know a little bit more. If the form requires Javascript it would be handy if it can switch to a php dependant version, should the user have Javascript turned off. I need someone whom can make fast changes and get this product rolled out. Future work will spiral from this as I am introducing it to a new customer who wishes progress with this every month. I will provide more information should I feel necessary or that it is important to the project.