Need Insurance Quote Sign Up

I'm seeking someone to create a signup script, similar to something at ehealthinsurance.com.

Basically, I want people to put in minimal information, like their zip code, and have that page lead to the application. I want this application to then be sent to healthcare providers that I have a list of.

If you're able to do this, please reply with your estimation on how long this will take and how much you will charge. If you have done this before, please link me to your work. Lastly, please have a portfolio so I can see your quality of work.

Since we're not allowed to post our email address, I ask you to please email me using the contact page at http://www.buyingindividualhealthinsurances.org because I do not frequent this forum too often.