Custom 1 page data capture into Database

I need a 1 page data capture page built which submits data to a MySQL database. I need 1 simple HTML page built, with PHP and a MySQL database which will submit the following data fields into the database. id = Primary ID (Auto Increment) categoryID = See the category List & Id's below (Select box Drop down menu, with category names) subcategoryID = See the SubCategory List & Id's below (Select box Drop down menu, with Sub-category names) country province City suburb listing_name = Business name description = business Description (Long text) address_street_number address_street_name address_area address_city address_postal_code phone Number cellular Number email website (url) facebook (url) twitter (url) Video (url) Instagram (url) gplus (url) image1 (Image upload facility) image2 (Image upload facility) image3 (Image upload facility) image4 (Image upload facility) lat = Latatude lng = Longitude Categories & Sub Categories: I will provide a list of all the categories and subcategories with their ID's which should match, for instance : 1011 Pubs, Restaurants, retail and service 2129 5 star Restaurant 1011 In the above example, Pubs is the main category with a ID of 1011, and the sub category is "5 star Restaurant" with a ID of 2129, but it's linked to the Main Category with ID 1011. Work & Payment terms: This work must be done on our server. We will set up the milestones, and only release payments if the work is done correctly.