First off I think you should use HTML and PHP to do this.
Create an HTML form with everything you want in it...have it post to "something.php"
Create "something.php" and rename the variables
eg.
$Email = $_POST['Email'];
Do that for all the variables.
Then do some validations like this:
if ($Email == "") {
echo "You left your email address blank.";
exit;
}
Then you can use the mail() function to email the info straight to the company...or else you can have it emailed directly to you...or you can use a mysql db...u pick.