Toxic Test landing page

I would like to have a copy of the site [login to view URL] on my webspace I have the mast head and the rest of the graphics. I already have webspace for it. I also already have a email constructed to go to it. I just need help putting the code in to make sure. I just need help making sure the fields work and the data is sent to me (phone, email name etc), and that we are emailed a list of the items clicked.