Custom Payment Form with Email

I need a straightforward web form that lets users enter their name, choose how they intend to pay, add the anticipated payment date, and then hit “Submit.” On submission the form must send a confirmation email to both me and the customer through Gmail’s SMTP (or the official Gmail API if you prefer).

Core requirements
• Single-line text field for the customer’s name.
• Drop-down list containing exactly these options, spelled and punctuated as written:
– Theconnection renew
– monthly
– check to treasurer
– credit card to treasurer
• Free-text or date-picker field for “anticipated date of payment.”
• A submit button that triggers two emails: one to my address and one to the customer’s, each carrying the details they just entered. The emails must route through Gmail so I can keep everything under the same provider.

Acceptance criteria
• Form loads cleanly on desktop and mobile.
• Both emails arrive with the submitted data in a readable layout.
• No third-party branding appears in the messages.
• All entered information is cleared only after a successful send, with an on-screen success notice.

If you’ve built similar HTML/CSS/JavaScript or PHP forms that hook into Gmail before, this should be a quick turnaround. Let me know your preferred stack and how soon you can deliver.