One Page Form for Club Membership

I need someone to make a 1 page web from using the file provided for the look and feel. The fields are as followed: name: Address: City: State: Zip: email address: Mac or PC: How did you first hear of Enterprise Computer: Friend, Yellow Pages, Newspaper, Coupon Book, Radio, TV, OTHER: It must have a send button that emails it to me and saves it to an Excel, tab delimted file on my website. It will be located at [login to view URL]