Create a lead capture form, and a backend email database

I have several landing pages that need a form which collects data and transfers it to a database where it will go out to the clients via plain text and/or XML type files. The database should have a back end to it allowing us (the lead provider) to turn on or off which companies get sent leads based on the amount of money they have available in the system. When the time in which a company is paid has expired or the lead budget is no longer available, the system will notify us letting us its time to call the company for payment. Some example sites of what I am looking to achieve is [login to view URL] or vanlines.com. A full website does not need to be constructed right away because this will only be a PPC project. This only requires one form that I can place on mutiple sites, to capture leads into a database, count how many leads each company receives per day, and have to ability to turn on and off different companies email addresses in the back end. Please PM me with any questions and with your previous work and budget requirements. We can speak more in detail about what features it should contain. The form should look something like this [login to view URL]