Simply create a WYSIWYG page.
Add a second (Form) section.
Read the stuff about forms in the
help pages.
Just by using a few "header" and "radio buttons" I created the sample below in 2 minutes.
Styling can be done in the settings page of the form (including the CSS).
Create a nice "thank you" page and select that page in the "Succes" dropdown list (Form settings)
The form will email the result to you. (set your email address in the settings page)
Ruud