Clone for a autoreponder cgi script

I need a clone of the autoreponder cgi script from this website [login to view URL] I don't own this website so I can't help you with anymore details then what you will get when you check the source code. Also I don't know if I need a special autoreponder for this script to work, If I do then I will need that too. I will also need the banner image similar to the one on the site but the text must be in a table format with the words ( [login to view URL]) on top and on the bottom of that the words ( Get The Credit You Deserve Today! ) The image is copyrighted so you will need to do a complete redesign