[REQUEST] Easy form mod

[febern]

Hi!

I would like to use a simple form on my site.

Content i need:

When the member click on it, he/she just fill the following lines:

- Payment type : (here he can choose from EUR,HUF or USD)
- Type of keep the contact: (E-mail, PM)

And a subscribe button. It would be great if the admin can get this form to admin's pm or mail address.

Please..................it's very very important for me