306 PHP form with CC to Email...

Simple silly project... A username and password is submitted to a form, which we do not control. Need to submit the username and password to the form and email the username and 'footprint': IP, Browser, screen resolution, OS, etc to an email address. So, need a script that will pass the username/password information to the form and email username and client footprint to an email address. As a bonus, would also like this information injected into a MySQL database. I would prefer to work with someone who can take care of this right now and is available by chat - but that is not required. If you can just provide the skeleton code, that might be all that is required here - perhaps 15 minutes of work for some feedback :) Thanks for your bid! WebGal