We need a web form

We require a simple web form.
The form will be bold in design, have approximately four or five fields, and the facility to email the submit or a confirmation reply. The actual form information should be set up to be sent to an email of our choice.
We also require the option to change the email where submissions go to, ie admin@, another email etc.
We require this job to be completed within 24 hours of awarding.