Develop a data entry form screen for event

We are looking for someone to develop a simple data entry screen on a Windows 7 laptop for use at trade shows for potential customers to enter their details into. The form needs to drop out the data into an editable database (Access etc) so we can use it in other forms and clear it when required. The basis of this form can be found at [login to view URL] but we need to: * Add date stamp of when the entry was made * Nationality * University Name * Remove Country field Formatting of the page will simply need to be single red background colour with a logo in the top right. The form isn't for online submission, just local Nothing fancy or complex!