This isn't trying to be difficult but do you want a membership form where people submit membership registration or is this a feedback form for people to contact you where they can select various preconfigured options in the process ?
Membership systems are typically used to register users for restricted content.
Getting a user registered is relatvely easy. Protecting the content you want to restrict is a lot more involved.
A form handler script can process a form and email the results of it to you.
click here for a very popular CGI form handler, or try Hotscripts.com and search for a form handler in PHP or CGI, which are the most likely languages your web host will support.