Custom form field programming

I want to ask a consumer 3-5 questions and based on their yes or no response be able to email that data. Need to create a database and the ability to add/remove/edit the questions and where the data gets sent. Basically it is a very small co registration path. The consumer will be trying to access a page in which they must first answer these questions in order to get to the page. I would like the 'form' to carry a hidden field so in the future I can use this same form on a sister site and have it still write to the same database. I must also be able to pull simple reports against the database. Need this done in 24 hours....