I created a PHP request form free hand in Notepad. I need help on how to integrate it into a Joomla! 1.5 template. I figured the request_form.html I would create in a Custom HTML module but I'm not sure how to create the php files in the template

Anyone here proficient in Joomla! 1.5? I posted this in the Joomla Forums website as well but haven't got any replys as of yet.

Here's the code:

request_form html

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">


<title>Request Form</title>

<body background="#EEEEEE">
<img src="pics\um-cross3.gif" height="100" width="100"><img src="pics\title.gif"><br>
<h3 align="center">Information Request Form</h3>
<form action="cgi-bin/feedback7.php" method="post">

<p><font color="blue">Thank you for visiting our website. If you would like more information, please fill out all the information in the form below. When finished, click on the "Submit" button. Be sure to include your address, e-mail, or phone so that someone can follow up with you.</font></p>
<hr width="100%">
<p>Name:&nbsp&nbsp&nbsp&nbsp&nbsp<INPUT TYPE="text" SIZE="35" name="name"></p>
<p>E-mail:&nbsp&nbsp&nbsp&nbsp<INPUT TYPE="text" SIZE="35" name="email"></p>
<p>Phone:&nbsp&nbsp&nbsp&nbsp<INPUT TYPE="text" SIZE="35" name="phone"></p>
<p>Address:   <INPUT TYPE="text" SIZE="35" name="address"></p><br>
I would like more information on the following (check all that apply):<br>
<INPUT TYPE="checkbox" NAME="Programs[]" VALUE="Adult Sunday School">Adult Sunday School<br>
<INPUT TYPE="checkbox" NAME="Programs[]" VALUE="Bible Studies"">Bible Studies<br>
<INPUT TYPE="checkbox" NAME="Programs[]" VALUE="Children's Programs">Children's programs<br>
<INPUT TYPE="checkbox" NAME="Programs[]" VALUE="Missions">Missions<br>
<INPUT TYPE="checkbox" NAME="Programs[]" VALUE="Music">Music/Choir<br>
<INPUT TYPE="checkbox" NAME="Programs[]" VALUE="Youth">Youth group<br><br>
Please add any additional comments or questions in the box below:<br>
<TEXTAREA NAME="comments" ROWS=10 COLS=60>
<p><img src="Cap_Img.php"><br><br>
<input type="button" value="Refresh Image" onClick="window.location.href=window.location.href"></p>
<p>Before submitting your request, please enter the string shown in the image into the box below.</p>
<p><input name="number" type="text"></p>
<input type="submit" name="submit" value="Submit"><br><br>
<hr width="100%">


feedback.php file:

<form name="form1" method="post" action="request_form7.php">
<div align="center">
<input name="Submit" type="submit" value="back"></div>
<div align="center">

$imag = $_POST['number'];
$user = md5($imag);
//echo "$imag  =  =  = $key<br>";
$checkbox0 = $_POST['Programs'][0];
$checkbox1 = $_POST['Programs'][1];
$checkbox2 = $_POST['Programs'][2];
$checkbox3 = $_POST['Programs'][3];
$checkbox4 = $_POST['Programs'][4];
$checkbox5 = $_POST['Programs'][5];
$formBody="Name:$name\nEmail:$email\nPhone:$phone\nAddress:$address\nI'd like more information on the following programs: $checkbox0, $checkbox1, $checkbox2, $checkbox3, $checkbox4, $checkbox5 \nComments:$comments";
$headers = "From:$email";

if ($submit) {
mail("me@yahoo.com", "Information Request",$formBody, $headers);
if ($submit) {
print "Thank you. Your request has been submitted <br /> <br />";
print "Current date and time :";
print date("F j, Y  g:i A T");
echo "You have entered wrong verification code!!<br> 
		Please go back and enter proper value.";

    $md5_hash = md5(rand(0,9999)); 
    $security_code = substr($md5_hash, 25, 5); 
    $_SESSION['count'] = $enc;
    $secure = $_SESSION['count'];
    //     echo "--------------------------$secure<br>";

    $width = 100;
    $height = 40; 
    $image = ImageCreate($width, $height);  
    $white = ImageColorAllocate($image, 255, 255, 255);
    $black = ImageColorAllocate($image, 0, 100, 0);
    $grey = ImageColorAllocate($image, 204, 204, 204);
    ImageFill($image, 0, 0, $grey); 
    //Add randomly generated string in white to the image
    ImageString($image, 10, 30, 10, $security_code, $black); 
    imageline($image, 0, $height/2, $width, $height/2, $grey); 
    imageline($image, $width/2, 0, $width/2, $height, $grey); 
    header("Content-Type: image/jpeg");