Customer feed back form and scrolling widget for website

I need a page created to enable customers to fill out a simple form on a page in the site for feedback on my website **[login to view URL]** When the customer has clicked 'send' the information then scrolls down a widget, which I will put on different pages throughout the internet. The comments page will be made with the template of the other pages on the website. and will include the following information: Thank you for choosing Ezy Air to install your air conditioner! If you have any comments or suggestions, we would appreciate your feedback! <p>Name: <INPUT FIELD> <br>Suburb: <INPUT FIELD> <br>Approximate Cost: (Optional) <INPUT FIELD> <br>Comments: <INPUT BOX> The second part of the project will to create a widget that can be resized to any size, and will include a border, a logo and the 'comments' scrolling through the widget. Please see the links below for an exact idea of what I want: **Please reference the following links before making a bid** <[login to view URL]> <[login to view URL]> (scroll to the bottom to see the widget that I want to copy) The winning bidder must be able to communicate VIA Skype between 6pm-Midnight GMT+10. I also need to be able to administer the comments VIA a basic CMS.