Simple form and image upload program

We have a simple form requirement for our web page. We want our website customeers to be able to fill in a form and then for the details to be sent to us by email. We also need the option for them to be able to attach an image to the form We therefore need a script creating to handle this. We also need the basics of a very simple compatible form creating for our web page, which we can then expand and develop ourselves, as required. The basic form template needs to include a simple text entry field, a drop down field option, a verifiable (double entry) email field, the image upload field and a check box where our T&C must be accepted before the image can be sent to us.