Build a Data Capture Wordpress Plugin for Petitions

I require assistance from an experienced coder to build a plugin (or database application) that would allow visitors to a Wordpress website to sign a simple petition. The information they submit should be captured in a database, and displayed within the wordpress dashboard. The petition form would have four fields: a. Name b. email address c. school district of residence d. boxes to tick selecting 1) parent, 2) teacher, 3) California taxpayer, 4) school district employee, and 5) other with a space to write in (should let them select as many as apply) It is OK with us if you use a pre-existing database technology or a third party code. The client needs us to perform this task TODAY, so the rush will be reflected in the compensation.