small job

On the website [login to view URL] I need everything right of the tree to be replaced with a black box, and on the black box I need a form put with the following options: Name Address City State Zip Choose the t-shirts you want (can do this with a checkbox for the ones you want, by labeling them with numbers) Then you can choose either (1,2,2,1) or (2,3,3,2) Then it needs to either a) load all the info in a email automatically or b) auto submit to me via email (but I dont know if my server can do that) I need this done asap, as in today. So please respond fast.