Form submission data and photos sent in a nicely designed email - repost

This is a very simple project if you know what your'e doing. First answer these questions or else I won't even consider your bid. 1) What time is now? 2) What's your favorite food? Project Description: I need a form built on a WordPress page (see page below) that when submitted, sends a well designed email to 2+ email address. The form will also include two photos uploaded by the submitter of the form. This can be hard coded and doesn't need to be run via a CMS but would need to be built on a WordPress site. Details: The following link will take you to the form that needs to be coded into the site: [login to view URL] A text field needs to be added at the bottom where the user can enter an email address. This is the person receiving the info from this form. I would also like this email to be automatically uploaded to my Mail Chimp account if possible. If this box is not filled properly, the form should not be submitted. I'd like to have 4-5 doctor's names listed with emails hidden in the code. Each name will have a check box next to it. The user will check one of them (possibly two) and an email copy of the form will also be sent to them. So in total, at least two emails will be sent when the form is submitted. I'd like to have two photos be included with the email. These photos will be taken by an iPad and stored on the iPad. The user will be accessing the form on the iPad and will need to be allowed to upload the desired photo. The photo can be resized smaller for easier emailing. Once the form is submitted, a well designed and formatted email will be sent to the specific email address. Basically, I just need the email to follow our company color scheme and include our logo, and contact information. It would be nice to have the data saved if possible but only if there's a slick method for doing so.