Need to set up a survey form which fits into the current template system

Hello! I need to set up a new page somewhat like a survey page. Customers will choose options and provide comments. And all the information will be emailed to me upon clicking 'submit'. This is not hard for an independant php page. But I need it to fit into the template system, so that the form is in the center column of the page, and the left and right column are still intact, displaying other product information. I am not sure how to integrates such a web form with the template. I tried to use product type and page_2 etc. They didn't work. EZ-page might work. But I don't know how to utilize the template in EZ-page. Anyone can help me? Thanks so much!

You can clone the contact_ us code and add additional fields. It is very easy as long as you don't want to store the information in the database.