Autoresponder Dynamic Opt-In Form

Here's what I am looking for: To see what I'm talking about... contact me for link. On this form... which pops-up after a button is clicked on a website... A Pop-Up box that has a transparent backdrop (which covers the webpage) will appear. You will be asked to enter your name and email address. Then after pressing submit, you will be asked for your address, etc. It's like a multi-step opt-in form I believe in dhtml. The data collected could be passed through to a autoresponder such as Aweber or a hosted database.