Create simple responsive database website

I need a responsive database website with a page to view the database as follows: - I already have a domain and hosting to use. I will provide you with the login details. - See attached reference. This was something created for me before. I just edited it now to show the different named fields that I now need. 1. I need a database website quickly done like the reference image with these these 5 fields: Name and Surname, Company, Designation, Mobile Number, Email Address. 2. Make the input blocks with a RED border (Same red as clients logo). Clients logo is attached as well. Make the submit button red not green. Add clients logo at the bottom of the page centered. 3. The page must be responsive. Its main use it to run landscape on a tablet pc with a browser. but it should be responsive to change to a phone or pc browser as well. 4. On submitting a thank you message appears. "Success! Thank you for entering in your details." It then clears the form so the next person can use it. 5, See below of pic. I need a website link developed to view the database. Time/date stamp which is set to GMT +2 time. Then also the 5 other fields. Time: This job should take someone a couple hours. You need to be able to start today. Budget of about $30 TO $40.