Website Questionnaire Form Needed

THIS PROJECT HAS TWO PARTS PART I: The company I now use is [login to view URL] (Free Service) unreliable. I need a web form that a potential client can fill out online and click the submit button and I receive the web form via email. Preferable a cgi script (Folder) to upload to my [login to view URL] webform I used is attached to this post "[login to view URL]" PART II: I would like to intergrate this webform with my current autorespoder company I use. I did it once before with a different autoresponder company. I would like for the client to be on my website, fill out the questionairre and be added to my autoresponder and have a email sent to me with the questionaire details. I can provide you with the other code I used and we can work together on create this new form with the new autoresponder. Please Inquire if you can do this job or need further explanation.