75515 Fun Flash Story Generator

I would like a nice looking module that will have about 5 questions on it, along with check boxes for responses. It will also ask for the persons first name. When the user submits the form, it will auto generate a "story" with their name in it. The dynamic parts of the"story" will depend on the answers that they provide to the questions. The "story" page will have an email box so that they can tell a friend about the module. This will automatically send an email to the friend with the persons first name in it. The design must match the look and feel of my site. It must be very clean and professional. I am looking to secure a long term relationship with the programmer chosen to do this project.