I need a form that I want to use on a number of different html pages.

The form will have three mandatory text fields and one (optional) numeric field:

The text fields will be:
email1 (the form has to verify that the email entered is a valid email)
email2 (let's them type the email again, to verify that they entered the correct email)
Message (limit of say 250 Characters)

The numeric field will be for a dollar amount, but it is optional for the user.

Once the user submit the form, the information must be emailed to an email address that I will specify.

I want the form to also gather as much information as possible concerning the user (without asking for it), including:

ip address of the user
html page the user came from (html referrer)
the url where the form was submitted from (since I will be using the form on multiple pages)


The form must have some form of spam protection and the email address to which the information will be send must not be visible in the html.

The form must written in php and html.