Create form and pass variable to dynamic tracking pixel

Hi, I need a very simple website submit form with the following fields: 1. Name 2. Emailing 3. Message. The form must go to a Thank you page that contains an Img tracking pixel. We're installing a new affiliate tracking system AffiliateWiz, and it works as follows: When a user clicks on an affiliate link, they will go to this form that you will create. After they hit submit on the form, I will get an email with their information from the form, and they will be forwarded to a thank you page. There will be a 1x1 tracking pixel on the page: <img border="0" src="[login to view URL]" width="1" height="1"> The number sequence 12345 should automatically be replaced with the email address from the form. Thanks!