Oscommerce Finance Form

I have a finace company that I use but a the moment just have a picture on my right column that links to their website. I would like to have an online application that gets sent to both my email and the finance companys email with details. The website that you can see the current is [login to view URL] I have attached a file with the details needed. I have had a quote from one person but can't get a hold of them to do the work. The form required should be similar to the "contact us" page on the website for layout. A one page document only (not moving between screens). Budget is low so please take that into consideration. HIGHLIGHTED TEXT IS COMPULSORY ENTRY BY CUSTOMER. "Online application" to be under Benson Finance Company Picture. Any question, please ask.