Customisable simple opt in form with 2 fields

I require a web form that can be implemented on a web site by a cut and paste (html). What the form needs to do is like a traditional opt in form, I want two fields. 1 ??" Name 2- email and a submit button. What I want the form to do when the fields are filled in and submitted (on clicking the submit button) is send an email to a pre-defined email address (customisable) with the collected information and redirect the user to a web page (again, this must be customisable, mainly be editing fields in the form itself). Nice to have is a level of customisation around what colours are used in the border of the web form (opt in box) and the text on the submit button be easily changed. Also, the title of the box easily changed too. The form must be a small box, with just the fields of name, email and the submit button, similar to most opt in forms found today.