Simple mobile website with embedded form

First, I need a mobile website that has the following 4 elements (basically it's just a very short survey form): 1. A multiple-choice question 2. An open ended question 3. Ability for the user visiting the site to upload a photo (when clicking a button, it prompts their phone to either i) take a new photo or ii) choose a photo from their library) 4. A 'submit' button so this information is sent Secondly, I need that information to be databased somehow. Either I can just receive it via email whenever somebody submits the form or it gets databased somewhere where I can access Lastly, I will want to make different forms with slightly different questions... so I need the site to be easily copied into another page that acts as its own independent survey/form I attached a short file that shows what I'd like the site to look like, but I"m open to suggestions This should be an easy project... don't overcomplicate it more than needed & LMK any questions!