499505 Contact Form

I need a simple small module of code i can insert into my website which will gather details from a client who is requesting a callback and send the data which has been input by the user to another server for processing. Please note, i can insert the code into the website myself so i just need the actual code to insert. The fields i need to collect are Title First name Last name Telephone number Email address This is a snippet i got from the provider which explains what i need to place in my website. You can also send form data straight to the software through the url to prevent multiple data entry for the client. The fields it accepts are 'title', 'forename', 'surname' and 'contact'. There are also fields 'd1', 'd2', 'd3' which can be used as generic fields to send extra data to the operator. Also include the variable cc=client code and ch=id code For example: [login to view URL] I am also looking for someone who can possibly provide a regular service helping out with simple bits and bobs as i manage a growing number of websites.