Web form

I need a web page form with the information below. The results would be sent to my email address. I want the information the user puts in the email field to show as the from address when the email comes to me. Payment will be made upon completion. Thanks! Name (required field) Email address (required field) [] Potential customer [] Existing customer (One or the other required) Existing customer – What name and email address did you purchase under (This option will only be active if existing customer is checked and will be required if active) Windows version [] Vista [] XP Home [] XP Pro [] XP Media Center [] 2003 Server [] 2000 Server [] 2000 [] NT (One of these is required) At the login screen, do you have a field below the password field that says Log onto? [] Yes [] No (One of these is required) Please boot with our CD and type retrieve at the a: prompt, then hit the Enter key. What characters follow the Administrator account and the account you are trying to log in with if other than Administrator? Please be exact! This information is very useful in getting you logged back in to Windows. (Here would be a text box to enter the information) (This would be optional) Additional information (Here would be a text box to enter the information) (This would be optional)