We don't have homework
We won't do your work for you
You have put no effort into it
Read the book with the class
It's 98% HTML anyway
Hardest part is validation
You say you need this:
Name: {input}
Surname: {input}
Age: {input}
Email: {input}
Password: {input}
Password Verify: {input}
City: {input}
My Own Field: {checkbox}
Now, using that, there's your HTML setup. Done!
Next, PHP. Get the form to submit to the PHP page (via the HTML <form> tag). Grab all the values into variables.
Make sure the name and surname aren't empty, the age is between 10 and 80, the password isn't empty, the city is within an array of cities, and see if a checkbox is checked.
Once done all that, if there aren't any errors, display a thank you page going over everything they put in.
Google RegEx Email Validation to find a suitable Email validator.
Like Kburger has said, we won't do your work for you. We're here to promote learning, not cheating.
~Brett