574418 Need web application / form with ability to generate more

I'm looking for someone to create a script that can create web form code that produces a form just like this: [login to view URL] But with a simple user/admin interface that allow us to: 1. Update the email address the completed lead form is sent to. 2. Enter a Company Name (Who generated the lead) 3. Enter a Lead Source Code (Ex: OUG123 or whatever) -- Rather than having this script generate web form code we would need to upload, I'm looking for a dynamic script that would instead create this form online, and generate a unique URL we could send to potential applications. For example: 1. Admin fills out online information: Email Address To Send: brett AT [login to view URL] (Scriptlance won't allow using actual email ampersand in bid) Company Generating Lead: Options University Lead Tracking Code: OUG100 2. Admin clicks 'Create Form' button 3. Script generates page and shows URL: [login to view URL] 4. Admin user uses this URL to send leads to after watching our sales webinar. 5. Customer / End User fills out form and hits 'Submit' 6. Lead information is sent to email address noted above, with the user responses but also at the top: Company Lead Source: Options University Lead Tracking Code : OUG100 So that our sales guys know who earned the commissions on these and for sales tracking. Should be fairly simple for someone who knows what they are doing. Need ASAP - Today or tomorrow latest! thanks!