HTML form WITH JSIGNATURE

Please do not bid if you cannot complete within 2 hours. I would like a simple HTML form created with JSignature. [login to view URL] I would like the user to be able to sign their name using JSignature and submit the form. When the form is submitted, the signature must be uploaded as an image, and the form data saved in a MySQL database. I have uploaded the image to show the form, and the MySQL database format. NO FRAMEWORKS PLEASE. The MySQL connection must be MySQLi Object-oriented, not PDO. Please do not bid if you cannot complete within 2 hours.