cgi registration form

I would like to allow customers to register their software purchases via a secure page on my current website. I can make the link in our software point to a secure page on my website. My current website does not allow upload of CGI scripts to run on their servers. However, you can upload CGI scripts on another web server and then you can reference these scripts from HTML within the page. I do have a server that supports cgi and php/mysql I need a simple cgi script and I need an attractive registration form with checkboxes, radio buttons, input fields. About 12-15 fields in all including name/address/operating system/interests/comments All fields I need will be listed upon acceptance of bid. My goal is to have the data submitted populate an access database.