Well, first you have to decide what server side technology you will use: PHP/ASP/ASP.NET/JSP/something else.
But in any of those, you are talking about only one page of server-side coding. Just storing the contents of a POST-ed <form> into a database table.
Choose a technology and then go ask in the appropriate forum.
An optimist sees the glass as half full.
A pessimist sees the glass as half empty.
A realist drinks it no matter how much there is.