Create a website form that will send results to access and email

I need to create a simple webpage that allows user to request office supplies. I'd like it be able to send the results to an email and to an Access database. Simple form that would have fields for name, office, phone, etc, etc... Then a list of office supplies with the ability to add a quantity. I'd then like the results to email our office admin staff and dump to an Access database. I'd like the access database that could produce some simple reports like: Requests by user; requests by date or date range; total number of requests for certain items, etc, etc.... I've attached the supply list...