Hi, if you deliver the graphics, the example is laughably simple in flash.
It's not that hard in HTML5, but I'd charge more, becuase of having to check browser compatibility.
I have 5 different quiz-modules in flash I could use, but seeing as you just need e-mail, it's the simplest one.
I could do it in 2 days, allowing for a round of checking for errors, but considering my agenda, I can have it up and working for you by the end of the month.
I can't put up contact info, so please contact me via freelancer.