Convert PHP/HTML Code to Raw PHP

I would like the attached file converted from html/php to a RAW php format that can be used in an IPBoard/IPContent block or page. That means no php tags. This will probably take less than 15 minutes of work for someone skilled in php. Please also clean up and fix the code if it needs it, make sure it works on IPBoard and does what I want it to do. It's supposed to be a registration form for a game server. Thanks!