Selling Yourself To Employers Online Database

Hi - I have a website (Posting of a link with contact details is not allowed in this site as this may result to account suspension by Freelancer.com Administrators) and have my book 'Selling Yourself To Employers' coming out in three countries through my publisher in Sep 2011. I have designed my own website, but want a very simple form created on one of its pages where people enter their First name, second name, Password (which is the always the same and never changes) and email address (which is then captured in an on-line database I can then access) and then go through to a webpage I have created where they can download some template I have put on-line. I also want the ability for them to opt out at the fill in the form stage. Thank you!