Custom Payment Form with Email

I need a straightforward web form that lets users enter their name, choose how they intend to pay, add the anticipated payment date, and then hit “Submit.” On submission the form must send a confirmation email to both me and the customer through Gmail’s SMTP (or the official Gmail API if you prefer).

Core requirements • Single-line text field for the customer’s name. • Drop-down list containing exactly these options, spelled and punctuated as written:

• Theconnection renew
• monthly
• check to treasurer
• credit card to treasurer • Free-text or date-picker field for “anticipated date of payment.” • A submit button that triggers two emails: one to my address and one to the customer’s, each carrying the details they just entered. The emails must route through Gmail so I can keep everything under the same provider.

Acceptance criteria • Form loads cleanly on desktop and mobile. • Both emails arrive with the submitted data in a readable layout. • No third-party branding appears in the messages. • All entered information is cleared only after a successful send, with an on-screen success notice.

If you’ve built similar HTML/CSS/JavaScript or PHP forms that hook into Gmail before, this should be a quick turnaround. Let me know your preferred stack and how soon you can deliver. Budget: USD 30–250 Skills: PHP, JavaScript, Website Design, HTML, Email Marketing, Web Development, Backend Development, Frontend Development