web capture form with image

I am looking for a form that captures a name, some text of around 100 words and (optionally) a picture on a website page as an entry for for a competition. The page should be able to take post values for the name field and if present, display the name in the name field. When a user selects a photo, it should display on the form (may have to submit). The image should be resized to fit 140 wide or 175 tall and cropped to fit remaining. The photo has a default image and is optional The form details are saved to a mysql database. An extra field indicates that the entry has been approved (default unapproved) Another web page will display a random set of 5 entries and display them on a web page. The whole entry and display form should fit approx 200 tall by 600 wide