Design a Survey Page with GetResponse Integrated

Hi, Function: I need an lead capture page with request to do survey function, after completing the data will be send to getresponse and partipant will be directed to a refer to friend page. If they refer 5 friend to participate in the survey they will be given additional 5 chances in the draw. Website must be able to capture refer to friend emails and send to these email immediately with a pre written email with sender name and email. Website will also store the refer friend email in a database or execl file in server. Design: Progessional, corperate and Web 2.0 style. To give away Free iPad and new iPhone for filling up survey Survey include 10 short questions. Specially design form and buttons. Able to use handwritting fonts to design wording. To provide icon and graphic like ipad and iphone Freelancer need to design a high conversion leads capture page, which the page will give free iPad and 1 lucky partipants every week and anyone who refer another 5 friends by giving their email will have additional 5 chances in the draw.