Customised HTML Form

Would like a form that requires user to input his phone number to make a web call. The form will be hosted on my domain. When the form is submitted, it is sent to another domain to process the call. Presently, after the form is submitted, the user is sent to the domain where the call is processed. I would like to have the user to stay in my domain and presented with a reply, "Your call is being processed." The user must not see the URL of the domain where the call is being processed. Would like to have another field for user to input his email address. After the form is submitted, would like to have the form, with the phone number and email address, emailed to me. Would like you to create a HTML page which will do what I want. The code must be generic so that I can put the page in any domain. You can see the present form and test it in action at this URL: [login to view URL] The form is working so just input any number so that you won't be called back.