Exit Pop-Up Script and Data Capture for WordPress Required

I use FlexSqueeze Theme on WordPress and I need an exit pop-up script made.

The script would capture a few details:
1. name;
2. email address;
3. numerical data 1 (drop down menu 1-10);
4. numerical data 2 (drop down menu 1-10);
5. numerical data 3 (drop down menu 1-10);
6. numerical data 4 (drop down menu 1-10); and
7. language data 1 (drop down menu of a selected list of words).

The data captured from numbers 3 thru 6 above would be plugged into a very very simple excel forumla (eg no.3 x (no.4-no.5) + no.6 or whatever) to generate a result number.

The result number and the language data 1 captured from number 7 above would be dynamically inserted into prepared text for an email automatically sent to the email address with Aweber.

Questions -

1. if i put this on eLance or rentacoder how much do you reckon it should cost to put together? It look like very simple code to me (but im no coder!)
2. what WordPress popup plugin should I use it with? MaxBlogPress Unblockable Popup or FasterIM Optin, or something else?

Cheers guys - your input is much appreciated.

Johnny C