VicidialNow Interactive Web Form

Looking for someone to write an interactive webform for VicidialNow ce-2.2.0-svn-1443 . I want the form to populate fields (customer name, address, phone number) from the agents screen ([login to view URL]). It will need fields for the agent to fill in information (contact name, date and time of appointment), then email all information to a pre-determined email address. I guess the form will need to be html and a php script to process the information. It will be hosted on our own web server.