So basically, if they type in a zip code between 85700 and 85775 I want it to post to: http://medicarechoicesofarizona.com/
If anything else is entered, I want it to post to http://www.ehealthmedicare.com like it does below. I guess JavaScript would be fine too but PHP would be great because this is for a Wordpress widget. Thanks everyone!
<form action="http://www.ehealthmedicare.com/find-coverage?allid=Med35993" method="post" target="blank" _lpchecked="1">
<p style="font-size:16px; text-align:center">
Zip Code: <input type="text" name="zip" style="width:60px; height: 25px;">
</p>
<p style="text-align:center">
<input type="image" src="/wp-content/plugins/medicare-quote-widget/ehealth-medicare-go.png" title="Find Medicare Insurance Options" alt="Find Medicare Insurance Options" class="go-btn">
</p>
</form>