I can do what you need using php - mysql, but in order to have this done in 3 days time i have to ask for a bit more money than what you have proposed since it will likely consume all day working time.
If interested let me know, or send me an example of your form and i will create a working example.
Question, design is also needed here?
Regarding the security of information, i will use aes encryption key, it's the most secure information encryption available.
Thanks for reading this.
Gustavo.