Need a website scritp

[Kay]

I know that it is simply but I need a form for my website where the user enters details and can click submit - here is how i would like it to be set out.
Thanks I will be paying points. 20 - 40points

User nameTEXT BOX HERE)
Email AddressTEXT BOX HERE)
Lottery Number4 drop down menus, each starts at 1 - 49)

Submit Restart Form - These are buttons of course!

The form will need to do the following.......

1. When you click 'submit' it will email the information that was entered into the form to me(gamez93@yahoo.co.uk) and to the person who sent it using the email address they entered in the form.
2. When you click 'submit' it will display a message saying; You ticket has been registered you will now receive an email with all the details and the steps you need to follow. Gamez93

Thanks I will be paying points. 20 - 40points

[Jake]

i will do this once i get home if you want, but if its for some sort of contest, you may want it to check the users ip and send you their ip too, so you knw if they do multiple signups with dif. usernames/emails... i wont be starting until tonight, so if soneone else does it first, go ahead.

[Chris S]

I could but other people have offered to help

[Chris S]

ok so i guess my help isn't needed anymore

(im still at school so i couldn't help)(damn school gets out around 3:25 EST)(man i want this day to hurry up)(im going to chinese food)(why are you still reading this)

[Kay]

Thanks Enigma when you get back from school you can tell me some more info about how you got it to send an email to the person who sent the form with all their details.

Just so you know I am setting up like some sort of online lottery game and you can win loads of points so I need a script for the person to register for a ticket - I have a script that randomly picks the numbers for the round check out my site to see some more information. showoff.x10hosting.com

Thanks

[Kay]

They can enter for as many tickets as they like. I don't mind you putting your copyright at the bottom of the page so I will take the FREE plan (i need a lot of money for the draw)

The website is at : http://showoff.x10hosting.com - Still need to change some information - please also comment on the design

1. There is no special hours to get another ticket
2. Can I have it so that when it sends the person their details it also has a link to the website and have a random ticket ID which will also be sent to be along with all the ticket numbers etc.: Ticket ID: 15476. That way I will be able to work out who won adn if they sent me a pm within 3 days with they ticket number etc