I need an online order form linked to my site

I need an order form linked to my website so people can place orders This will not be linked to a shopping cart. I have 4 products in 2 sizes so shopper will be able to click on the order page and I will have some text and below this Name Ship to Address City State Post Code Country - ONLY AVAILBE IN AUSTRALIA Phone Email Products (From a drop down menu you will have the 4 products) Weight (From a drop down menu you will have 2 weights 3Grams and 7 Grams) Quantity (From a drop down Menu you will have 1 to 200 with 1 being at the top) A Comments field max 2000 characters Send button I want to receive this as an email so I can create an invoice and email back This needs to be incorporated into the site and look attractive. You can use a script if you want but this should be very easy and I am willing to pay $30.00 I need you to show me a sample of what you can do