Simple PHP "request a phone call" type page

[KuJaX]

I was curious if anyone knew of any simple PHP coding/software for a "request a phone call" type page.

What I mean is that I want a little graphic that people can click on, and they can fill in their information such as their name and phone number. They can then choose from a drop down menu of "as soon as possible, 10 minutes, 30 minutes," or maybe they can specify when they would like for the call to happen. Then when they submit the form it e-mails me the information that they put in to give me a heads up that I should be making a call in XX amount of time.

Thanks!

 

[KoMiT]

<CENTER>
<FORM METHOD=POST ACTION="mailto:someone@$nailmail.com" ENCTYPE="text/plain">
<INPUT TYPE="text" NAME="username"> : name <BR>
<INPUT TYPE="text" NAME="email"> 
: Phone Number <BR>
<label>When
<select name="select">
  <option value="ASAP" selected>As soon as possible</option>
  <option value="10minutes">10 minutes</option>
  <option value="20minutes">20 minutes</option>
  <option value="1hour">1 Hour</option>
</select>
</label>
<INPUT NAME="redirect" TYPE="hidden" VALUE="index.html">
<INPUT NAME="NEXT_URL" TYPE="hidden" VALUE="index.html">
<BR>
<INPUT TYPE="submit" VALUE="Send">
<INPUT TYPE="reset" VALUE="Clear">
</FORM>
</CENTER>
<!-- END OF FORM -->

Tell me if that works for you