Create a questionnaire form in html5

Your mission if you choose to accept it will be to create a customized contact form and adding it to an existing html based webpage. Ideally this would accomplished using this, which I already own : [login to view URL]?WT.ac=category_item&WT.seg_1=category_item&WT.z_author=jigowatt The contact form will include 2 hidden fields that will be populated by data passed from an aweber based opt-in page for users names and email addresses 2 drop down fields asking users what style of house they are looking for and how many bedrooms they need Lastly 3 text fields I need to be able to dictate which email addresses the form will be sent to when its filled out and when the form is completed you will create a quick tutorial either through screen recorded video or with screen shot images how I can add or change questions and email addresses the form is sent to. Thank you! Please write the word Apple in your bid description so I know you've read the project details entirely. I need to assign this project quickly..