WordPress Exit Pop-up Script

We use FlexSqueeze Theme on WordPress and we need an exit pop-up script made.? The popup should work with? Action Popup plug-in for wordpress or some equivalent plug-in. The script would capture a few details: 1. name; 2. email address; 3. numerical data 1 (drop down menu 1-10); 4. numerical data 2 (drop down menu 1-10); 5. numerical data 3 (drop down menu 1-10); 6. numerical data 4 (drop down menu 1-10); and 7. language data 1 (drop down menu of a selected list of words). The data captured from numbers 3 thru 6 above would be plugged into a very very simple excel forumla (eg no.3 x (no.4-no.5) + no.6 or whatever) to generate a result number. The result number and the language data 1 captured from number 7 above would be dynamically inserted into prepared text for an email automatically sent to the email address with Aweber. The pop up needs to be attractive with clickable boxes and a couple of graphics.