Myspace PHP / Data Form

I am looking for someone to create code for simple 2-3 field form that I can copy and paste on to Multiple Myspace accounts. I also need to be able to enter custom text at the top of the form for different clients, for example one form might say "Enter to win a free tee shirt, submit your name and email address". Once the person hits "submit" on the form I need to be able to tell which form or clients page it cam from, if this can be done by the subject line that would be great. I need the data submitted to be emailed to me at a specific email address that can be changed. My goal here is to find the easiset way to be able to capture email addresses from people on Myspace. One more thing that is very important! Myspace currently gives a warning when a link is clicked, or any information is submitted and transferred to a website outside of Myspace, if there is a way that this can be avoided let me know. If you place a bid, please explain exactly how this will work and what you will need from me to make this happen, I am not a technical person.