Duplicate form From One Site To Another

i need same form like this [login to view URL] on my site !!! Just the form and the three buttons and truck and the form should email to me and the email should be formatted with tables!!! Instead of the three button, please put those inside of the table above (above the submit button) and use a option button so the user can select which one they want. For now, after they submit the form, no matter which option they selected redirect therm to google.com. But I will change those to the different urls of his payment pages in a few days. i need with in maximum 1 hour !!!