Buying HTML FORM and PHP SCRIPT

I got an html form, wich is the basis of a more complex one, but here it is:

<table cellspacing="10px">
<form action="test.php" method="post">

<tr>
<td>choice 1</td><td><input type="checkbox" name="@1111@|_|" /> checked yes for test</td>
</tr>

<tr>
<td>choice 2</td><td><input type="checkbox" name="@2222@|_|" />not checked for test</td>
</tr>

<tr>
<td>text 1</td><td><input type="text" name="@3333@|_|" value=""/>input text</td>
</tr>

<tr><td><input class="bouton" type="submit" value="Générer" /></td></tr>
</form>
</table>

Code (markup):

It contains the input fields, 2 of them are checkbox, and one of them is text.

Please notice name of each field. "@1111@|_|" for field one and so on. the field are allways four numbers, this is also a valid name "@1234@|_|"

Now,

when a checkbox is checked, for example the one named "@1111@|_|" the php script should echo: "@1111@|@NA1@|" for this niput, and it it was the checkbox named "@2222@|_|" it should output "@2222@|@NA1@|" and so on.

When a checkbox, is not checked, the php script should echo "@1111@|@NA_@|" or "@2222@|@NA_@|"

When a input of type text is field, the php script should echo "@3333@|text inserted in the text field of the form|"

So, if i had checkbox 1 checked, checkbox2 not checked and input text containing this text "Hello World", and would want the php script to only echo:

@1111@|@NA1@|@2222@|@NA_@|@3333@|Hello World|

Whos willing to do this ? If you are, pm me, with a price quote and time frame.

 

In reference of the requirement of a Professional Php developer, I would like to bring your attention towards my profile.

I am Dhiraj Pandey, a full-time independent developer, Wordpress consultant and web evangelist based out of INDIA with a 4+ years of industry experience.
my email id is

Cost :: $30
Time :: same day.

 

20 bucks about an hour

 

Job Done Payment received in the time great buyer.

 

Have you fixed this problem now? I can do this for you, please PM me, thanks.