Hi doggy,
I think you'll be lucky if something just gives or writes you a script ... the forum is really for people who have got stuck, whatever, whilst doing it for themselves.
How far have you got ... the form itself is just HTML. The 'response' to the form (form action) could be in PHP, Perl, or whatever. Most of the scripts on places like hotscripts are again for people who know what they're doing, but just don't want to 're-invent the wheel'.
Even if someone did help you to get going, you're going to have to know how to adapt it to fit your particular needs anyway.
Paul.