Wordpress Insurance Quote Form Setup and Posting

I have a WordPress site comparing different insurance quotes. Requirements: (1) Modify the existing WordPress template to match look and feel of mock ups (mostly graphic changes on header, navigation tabs, body, and background) (2) Add an UI interface (e.g. [login to view URL]) to allow users to submit the following fields (below is an example, not the final ones) on the homepage: - firstName - lastName - zip - email - birthdate (calendar selector) - gender - country (2) Create a WordPress page that displays the results in a matrix (e.g. [login to view URL]). Results are based on the user input filtered by a set of predefined data from a spreadsheet. The user information will need to be stored my SQL database on my server. (3) Automatically posted via xml to and redirect to quote forms on roughly 10 affiliate sites. (4) Must support Firefox, Chrome, Internet Explorer, Safari (5) WordPress template must be built and tested on WordPress 3.4.1 (6) You'll need to create and host a demo site where I can validate that all the requirements have been met. After all functionality has been verified and tested, you will need to give me all the WordPress template files and any other relevant files (e.g. mySQL schema, WordPress config files, etc). You'll need to be available to help troubleshoot any problems that I encounter in getting it set up on my side. After I can successfully get these files working on my server, then I will execute payment. Please let me know if you have any questions before you place a bid. I can send you a more detailed mock up if you are interested. Thanks in advance.