Registration page

This is a simple project with very little time - need this done today. Urgently need a data capture page in the look and style of the document located at www worldbarguide com / webpage.pdf.zip. The page needs to write to a table on our database (you will need to create the table). Page needs to work in all major browsers including older browsers IE 4 etc. I DON'T have an HTML version - need this created to look like the above doc with all fields mandatory EXCEPT guardian. Date Of Birth should be 3 drop-downs DAY (0-31) / MONTH (JAN,FEB,MAR etc.) / YEAR (1970-2000)