567120 Facebook App / Widget

I need a facebook app or widget that will collect users email addresses. The user will simply enter their email address into an email form field & press a submit button. The email address will then either be collected as a csv, xls or raw text file. Alternatively if it can be in a format that can link it to mailchimp that would be ideal - but is not essential & is of secondary importance. Design will be provided - I just need the coding undertaken. Please give me a price for the app & examples of your previous facebook apps. Please only bid if you have experience of app development. Specific details as to length of time to complete the project & price will take priority in any bids. Good luck to all. I look forward to reviewing your bids.