html email autorepsonder form

I need a form that generates a customized email automatically. The email needs to have a user option to be either text only or html. If they choose html, then a background image will load with a colorful script font including the name and data fields of the submitted email. The autoreponder email needs to be customized to fields filled in the form. The initial form will have: Choice of email to be text only or html version to see images Fields: - Date - Auto Reponder inclusion - Form body (this allows an email to be written, but will not effect the response) - Name capture from the salutation, to be included into the auto response. A field on click that will generate an added response. A spam question capcha field. Would like to be able to choose the words or questions to control this feature. - Captcha field for spam The autoresponder email will insert the name and date fields from the submitted email and generate a personalized letter. If a toggle is selected, it will then generate a p.s. response to the bottom of the email based upon a "on check" command. The email is hosted on godaddy linux server and must work with their server. We can utilize another server is required for the form to work the way we need it to.