A Small Application/Widget for Web/Desktop

We'd like to create a small application or widget that consists of a questionnaire that a consumer would fill out regarding their habits/practices, that would result in a range of product recommendations for them. If programming for something like this already exists, no need to reinvent the wheel, but we'd like someone to set it up for us. We would like to be able to supply this widget to our retailers so that they could put it on their websites, and also have it available so that they could put it on a computer desktop and have someone fill it out in-place. So I guess that means it would need to be platform-independent and relatively stable. And, if we could create it so that the result that is generated at the end of the questionnaire is printable, that would be even better. If I have left off any important information necessary to consider this project, please let me know.