Web Inport Form + Print Page

What I would need is a form in any format. See the attached file for form info and fields. This will be web based input form KEY FIELD is the HWB# this field has to be filled in with a current next number in squence starting with a D##### (pound signs are number places) After the form is filled out I'll need a submit button that will send the form to an email address and if it is easy to a database on a website that I can read later. Thanks Mark Rogers Second when the end user hits the "submit" button I will need a pop-up window that comes up so they can print out a few of the fields they have inputed Fields Needed on popup page Shipper Consignee * these need to be right accross from each other half page of paper with each Then on the bottom half of the page Pieces - Description - Weight Class -NMFC# - HAZ COmments