Contact Us page with Information

Avg Bid (USD)
Project Budget (USD)
$30 - $250

Project Description:
I am looking for some help with my contact page. I am looking to keep the information on the contact page that I have here:

However, When you click the Request Quote button, I need you to be brought to a Thank you Page. Right now it does not do that.
I need all the user added information on the left to be emailed to us when a user submits the form.

I also need the following Information on the contact us form:

Referring URL
Users Web Browser
Users Screen Resolution
Landing Page
Search Engine used in finding our site
Pay Per Click or Organic
Keyword they typed into Search Engine
Position of Keyword if Organic
IP Address of User
Date and Time Stamp

Thank you very much.

Skills required:
Javascript, jQuery / Prototype, MySQL, PHP
About the employer:
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