Create Email Form using Dagon Design Script

Hello, I have setup an email form using the dagon design PHP form mail script but need the values input into the script. If you look at the form at [login to view URL] I basically require these values to be emailed to an email address of my choice, including any attachments. The verification code is also required. I have attached the form mail script that I'm currently using but if you already have a form that does exactly the same thing I'd be happy to install it.