Customer service form with AJAX+DOM

I need to create a web form very similar to [login to view URL] I also need to check that entered email is an email address and that "confirm email" is equal to previous field (email). Note that you can add more "requests" in section 3. Note that each "game" has different "component types". This connection should be easily editable (XML file is gooed enough, no editor needed). The form should be sent via email in a well readable shape. I do not need any graphics or design. Deadline is: ASAP.