Custom form script code and integration

I have code installed on my server for an ecommerce package, there is a section in this code which allows me to generate a detail capture form (e.g name, email) in html so i can get subscribers for my autoresponders. These details are then stored in my subscriber lists area. I need someone to quickly edit this code so that I can create some forms that capture extra details from my visitors. Such as: First Name: Last name: Email Address: Address 1: Address 2: City: County: Postcode: Country: Phone: Where did you here about us: Once the form has been completed the details go into the view list section under recipients. You can see the name and email of the subscribers i want to be able to click on the name and see all the other details captured by the form. If you want to have a look at the script installed on my server please go to [login to view URL] user id: 4 Password: lemon666 If you then click on the follow up section and click create form this is the code that i need changing. I need to be able to create a form that captures the details that i have listed in this project description. Once the form has been completed the details go into the view list section under recipients. You can see the name and email of the subscribers i want to be able to click on the name and see all the other details captured by the form. I don't really think this is an over complicated job and shouldn't take the right person too long to complete at all. If you have any questions please get in touch ## Deliverables 1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. 2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables): a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment. b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request. 3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement). ## Platform Perl MySQL