Add an email box to my oscommerce site

Hi, I have a highly customised oscommerce store and I would like to have a box on the homepage to capture email addresses of visitors. It would appear on the left hand screen and be a rectangle box with a few words to explain the benefits of submitting their email address to recieve newsletters. There would be a space for them to input their email address and a submit buttom which sends their email address to an email of my choice. The box would need to be customised to have the look and feel of my store at present. I expect turnaround in 5 days and I require someone with very good English. I welcome offers from countries in Asia, Eastern Europe, South America and those that have good skills for a low price.