One simple mobile webpage

I just need one mobile webpage made. It needs to contain the following: 1 form asking for: Name: Address: Phone number: Return trip needed? (Yes or no) If yes chosen above then a form field should appear asking for time for return. and a submit button. I will handle all the backend programming, just need a VERY user friendly page with the above. *****For a nice tip the above form should ask for one of the above information at a time, then on the last question show the submit button, of course all the form info should send to a specified URL when the submit button is pushed.**** ****Extra huge tip will be given if you can make the page rocket or space themed^^^