Bootstrap PHP / MySQL Simple 2 Input Form ( Responsive )

I am attaching the exact form style that I need you to build. It will need to have the logo centered above the form ( just as seen in the example ) - the form will need to submit to MySQL and store: Email Address First Name DateTime of Submission On Submit - We need to display a thank for message for 2-3 seconds and clear the form to be used again. Max Budget $20