Ad business listing form with Google Map Placement

Hi, I have a directory business listing website and I like to have a sign-up form so businesses can easily add their listing. Project objectives: 1. Create a form similar to [login to view URL] Disregard the top search header, logo, links, etc and bottom content. I will provide top square banner for the top of the page. 2. The form will contain all the fields as guialocal form. I will provide drop down list for country/state and category listings with corresponding sub-categories. 3. The form should also include the following fields: - Phone number - Fax number - Website - Email address - Upload 1 photo (250px-300px) - 10 key words, - Add 1 video link code. 4. Most important! The form needs to have the Localizer function exactly like the sample site. For example, if you select a Country and city, the map displays the correct location. Then, users can pick up the pointer and place it in the correct spot. (this is very important since my directory is in Mexico and Google maps is mostly incorrect). The address the user enters in the form should not dictate where the pointer is placed. 5. All the form data should reside in a MySql table so we can easily export it. The images should be placed in a folder. I hope I described the project sufficiently so everyone can provide a good quote. Lastly, I have an event form that I would also like developed so there is continued work after successfully completing the sign-up form. Thanks, Cruz