Make the form > have it submit the input to a script > script process the data and sends it. If you know how to write HTML forms, create the questionnaire using the appropriate tags. If you don't, it's not hard to do. A web search will turn up lots of examples of how to do this.
The next part requires a script. You can either find a specific one to do this (try Hot Scripts) or install a generic one that you can then use to process it and all the other forms you may need in the future. Form Tools will do what you want, as well as store the data in a MySQL database for you and let you sort and export the data as well. It can process different forms for you, even ones from a different domain from where you install the script.