Develop and integrate a facebook app that captures and enrols

we are looking for someone to develop, design a facebook app and integrate it so we are looking for an end and end project to be delivered. The app needs have the following: text provided by us a date icon that can be updated an apply now function that captures captures customer , email addresses, name i need to have all collected data captured in a database that can be used to email clients back 'this needs to completed in 10 days'