Add a page to request additional information

I would like a single web page that users can input several items of data to receive additional information. Users will submit the following: 1. email address 2. address 3. City, state 4. zip code 5. telephone area code(s) of interest 6. metropolitan areas of interest 7. State of interest items 5, 6 and 7 relate to location search that our company will perform on their behalf. Web page needs to retain the same styling, layout as the pages on our website: [login to view URL] data received from users needs to be stored for future use. We use [login to view URL] for our web server. Please check their site for different options for data storage. I need to be able to access the data easily and am willing to consider your best thoughts for data storage and access.