Develop Mobile-friendly Form/Widget

I would like for someone to build me an interactive form - similar to this one (link below). It needs to be mobile-friendly - so obviously not Flash-based. I would like it to have similar functionality - submit form, display results in a few tabs, etc. It needs to be easy to tweak (colors and a logo) and easy to install into various websites that I have no control of... however, I do need to somehow get the form submissions copied to my server - or through google analytics. [login to view URL] Please explain how you would develop this... if you can provide examples of things like that that you have developed, please do. Payment in full upon completion and validation of project.