Create a questionnaire to embed on website, capture data (name etc) and email result

General information for the website: i am a natural health practitioner
Num. of web pages/modules: 1?
Description of every page/module: Create a questionnaire to embed on website, capture data (name, email and telephone, location - to integrate with constant contact if possible or somewhere) and email results of the questionnaire to both me and the client.
Description of requirements/features: i have a sample of teh questionnaire - basically it asks about symptoms and you have to give a score from 1-4
- there are 65 symptoms to score. i have a wordpress site.
CMS and Admin requirements: i have no idea!
Extra notes: http://parasitetesting.co.uk/ - this is a very bad example - if you look at page it says on left in a box to click to complete the parasite questionnaire. i dont like the fact that this one doesn't have an obvious scroll or that it says application form but this kind of thing i guess.

the questions are here attached.