Simple web app - web form with conditional logic that pulls from web database (Lakeland) - in Lakeland, Florida For Sale

A client needs a simple web app that is integrated into his WIX.com site - it's really just a web form that pulls from a simple database (I have an Excel file):
User selects State from drop-down menu
Application displays a second drop-down with the cities in that state
User selects City from drop-down
Application displays list of venues in the selected city in a drop-down
User selects Venue from drop-down
User selects date range from Calendar
User selects Meeting Template from list of possible Meeting Types
Application returns an html page with the following dynamic information pulled from the form:
Location: City, State, Venue
Date: Month, Day, Year
The html page will also return static information based on the template they selected.
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