Create a brochure request that records email address

To create 2 add on webpage in the same style as the following - [login to view URL] [login to view URL] Each of the pages will be added to each website so customers can enter in their email address in to the form (with captcha), once their email address has been entered our downloadable brochure will pop up with the option to save/download. We want the email addresses captured to then automaticaly be emailed (address only, no other email content) to our email address which we will provide. This brochure can only be downloaded once the customer has entered in their email address and the correct captcha result. These 2 webpages (and files) will need to provided to us in to 2 seperate folders called "brochure" and will need to work independantly from eachother as we will be placing them on seperate servers