Just a note, this form doesn't do anything to your email address. This is just a form handler that I started with. It has no catching mechanism, just passes variables.
Please select your payment plan:
$120 / year (200 Mb of space, 1 Gb of Bandwidth)
$240 / year (1 Gb of space, 2 Gb of Bandwidth)
$480 / year (5 Gb of space, 10 Gb of Bandwidth)
Select your domain name:
. SUFFIX (select below)
Please enter your email: