Create a customer feedback for with star rating and comments box.

I need a form to go on my site for clients to give their rating & feedback using a star rating system and a box for them to leave comments - like this one: http://www.commentics.org/demo.php?cmtx_page=4#cmtx_comments It must have captcha and my authorisation for each comment efore being posted. Also if I could edit the file to adjust text/character length for comments that would be good.

I can easily upload necessary file to my site using FTP, so just need someone to build the page. I want to put this on an 'add on domain' so will not be going on the main hosting domain. I have heard that there could be issues with this - but am unsure? Apparently a simple script can sort this?