Using an API to display results on a page from information entered in a form!

Its a really simple project its's half done not much to get it completed user will enter data on a landing page and get back results based on the data they entered. You will need to add additional text fields (for DOB, Length of Time and etc.) with corresponding PHP and Javascript code and use an API to display results on a same page as well as send it to Zapier. Please add comments on where the code is altered. More to come if you get this right. This is a rush project need a 12-24HR turn around. PROJECT IS CONFIDENTIAL.