554580 PHP Form Needed

I need a form that allows me to display the company name, email, phone, web address and phone number of the listing. In addition I need when the form to capture a screenshot of the website to create an auto thumbnail in the listing using thumbshots(dot)com The listing page should display up to 25 results at a time before the user has to click on the arrow to see additional results. At the top of the listing page there should be a search selection for the user to beable to select the viewable results by specific category selected from a drop down menu. There should also be included a search box where they can type the name of the listing to search for in the specific category or select to search all categories. Need a separate for that allows them to submit the information that will display on the listing form. The form needs to have a captcha phrase required to submit the form that says "Prove your human 12+3=" with the answer being 15. Once the information is submitted it needs to bring them back to the submission form providing them with a confirmation message stating "Listing Successfully Submitted" you can see a screen shot of the listing form i need here tinyurl(dot)com/6pch8zc