PHP Form mail

We want to make form Mail with the following fields 1) NAME 2) EMAIL ADDRESS 3) MOBILE NUMBER 4) MESSAGE (Not More than 160 character) 5) CAMPAIGN DATE AND TIME (This should be at least three days ahead of the time request is made) 6) SEX (Sex you wish to target) 7) AGE (Age range you wish to target 8) LOCATION (Location you wish to target e.g town, point of interest etc) 9) SPENT ( amount range spent by target on recharge monthly) 10) MOBILE OPERATION SYSTEM (This is the operating system you want to target e.g BB, Android, windows etc) 11) PHONE TYPE ( this is the phone type you wish to target e.g nokia, samsung etc) 12) QUANTITY Form will be submitted to our email and a reply sent to client --