CGI Form Programmed

Our website [login to view URL] currently uses a form to redirect users to various pages depending on their "vehicle type" selection. We want it to continue to do that with a new feature. The zip code field should be replaced with a field for "email" along with a field for their first name. The email address and name will be emailed to me and the user will be redirected to a page based on their "vehicle type" selection. Currently the website design is in css design format and will need to remain in that coding type. The email address and name field will need to fit the current design in a pleasing manner. I can deliver the current php script that is used to accomplish what the form does now for addition of the email/name field being sent to my email. (If user fails to input a name and email address script alerts them to put a name and email address in before advancing.) If you can code something like this and fulfill all of the above details we are interested in working with you. Please contact me with any questions you have.