As you will be emailing this form to me with the information (when you click the submit button), I will respond to you using the email address provided unless otherwise specified in the comments area.
A word about emailing HTML forms. The data you enter here is automatically put into a comma delimited file attachment "POSTDATA.ATT", and when you click submit it is emailed to me at email@example.com using your email program on your computer. This email will be in your sent folder, and you can view the attachment with any text editor (notepad). Note that when you click the submit button, you may get a couple of pop-ups warning that you are sending this data via your email - just click OK/Send until sent. It depends on your email program and I notice outlook express does this.