Wordpress PHP Development - Collect email address field

We have a site and when you select one of the categories we want it to take the user to a page where they can put in their email address. Right now we have this already, but the email addresses all go into one field. We need them to go into different fields based on the category that the user picks. Then we need to be able to see email addresses by category and export them. Time limit is 2 hours. Put the word "cake" in your bid so that I know you read this.