App to create and send custom form

I need a simple Android / iPhone mobile phone app that lets the user create a custom form (with some fixed variables). This form should be saved either locally or in a database, and it should then be possible to register these variables every day, and then send it to an e-mail adr, phone number or database. In more detail, it should do something like the following: 1. Front screen with following headlines: My targets Register 2. When clicking «My targets», it links to this page: HEADER «My targets» - Text field with label «My initials» - Text field with label «Recipiants e-mail» SMALLER HEADER «My personal variables» - Text field with label «Nr. 1»: (Open text field behind this label) - Drop down box with label «Register how?» and options: Yes / No Scale 0-10 Frequency 0-10 Minutes Hours Kcal Kg Other BUTTON with label «Add new» which adds a new variable with label «Nr 2», and the same open text field and drop down box as specified over. This repeats itself, with the possibibility of adding as many variables as one wants. WHEN FINISHED REGISTERING VARIABLES: Needs a way to save changes and return to main screen. Also needs a way to delete current variables if the user wishes to do that. 3. When clicking «Register» (from main page): Opens a new page with HEADER «My custom form» First item: A way to select day / date of registration Then: The data from «My variables» is collected to make up a form that is to be filled out. Example: If the user writes «Sleep» as variable Nr 1 in the registration, with «Hours» chosen from the drop down box, and «Meals» as nr 2 with «Frequency» chosen as option, he will now see a form that looks something like: 1. Sleep (slider or drop down-box with label «hours», range 0-24). 2. Meals (slider or drop down-box with label «frequency», range 0-10). AT THE BOTTOM: A «Send»-button, that sends the information either to a database or to the e-mail-adress specified earlier as «Recipiants e-mail». Confirmation that the data was sent. I want this app created and then help making it available on the market for Android and iPhone Apps. I have made a prototype in jQuery, but can not get the "Save"-function and "Send-function" to work. I can send the prototype if the text is unclear as to what I want. Best Wishes, Bergkamp