Form needed - Can be exported into Excel - Joomla by MartianTeam

I need a form for a Joomla website. Look at attached image. I want form to be in a module. After website visitor submit information, I want that information to be saved in component. Then website owner can go into the component, and export information to Excel spreadsheet... (Budget: $30-$250 USD, Jobs: Javascript, Joomla, jQuery / Prototype, MySQL, PHP)
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