Create Web Form to Email

All I need is a php form to email processing file creating for the form (see attached). You will see a select menu (Branch) in the form, the user would be able to select which Branch is closest to them and depending which they selected the email would go to the email address associated with that branch. I must also be able to use this in future, so it needs some sort of config file so emails, required fields etc can all be configured easily. The form itself is already built, you just have to code in the desired functionality. I will give the winner FTP access so they can work directly on the file. For the right person there will be more work in the future revolving around php/mySQL/cms development. Please give examples of previous work so I can assess your skills.