Customer Kiosk

I need a small application that will run on a Touch screen in my shop. It should offer the customer the following options, 1. Notify me of Sales and New products (This option requires and Entry field for a Cell Phone number) 2. Customer Comment on Store Improvement (general text box for entry) 3. Same as above but should say customer complaint All above inputs must be accessable from another PC on the network and must also provide the customer with an on scfeen keyboard, Also must be based on the attached colour schems