Php web form with Mysql integration

Spec for a web app

Objective: Allow users to match different combinations of Retailer and combination of Supplier and Product, using data from a MySQL table.

The form will consist of two steps, with the second being optional, depending on the outcome of the first.

The first page will have:
Field 1: Researcher name (with regex validation): A text box
Field 2: Retailer name: A text box that will look up matches on a MySQL query, and allow the user to select the correct one - Format: Retailer Name [IRN0001]
Field 3: A similar text box to Field two, looking up a different MySQL query. In case there are no matches, the user will be prompted to manually specify a combination of Supplier and Product.
Field 4: Confidence level (sliding ruler 1-4)
Field 5: Source (URL)
Filed 6: Notes (text)

Page two:
Field 7: Supplier name (autocompleted with existing suppliers from SQL query, optional)
Field 8: Product name (autocompleted with existing products from SQL query, optional)

I will also need assistance on how to implement it and host it on a server.

Please feel free to contact me in English or Portuguese