Private Applications Feature

Hello,
I have created my website on Forumotion for my Minecraft server network.

Founder: HexLazer205 (That is who I am.)
Website URL: Click

I am currently working on the site for my Minecraft servers and I need to make unban appeals and staff applications. However, I would not like this to be done on a forum. I want it done privately so my users who want to apply for staff or apply an unban appeal to be done on a separate page (portal). I would be thinking it's done with a certain code in a widget, but I don't know. I am also fine if it requires the CSS Stylesheet. I want it to be so when they finish their application, it only gets sent to moderators/admins. I am planning it to be stuff like:

Question |"""""""""""""""""""""""""""|
             """"""""""""""""""""""""""""
In that box above this red text would be their answer to the question. Also, I also want it so there are multiple-choice questions they can select from and it would determine if they are right or wrong. If you do not understand, perhaps I could explain more. Thanks in advance!

How about by private messages (staff applications) and contact link in the footer links (ban members)?

Well I don't want it like that. I want it so it looks something like this:

Age: |""""""""""""""""""""""|
        """"""""""""""""""""""
Strengths: |""""""""""""""""""|
                """"""""""""""""""
Weaknesses: |""""""""""""""""|
                   """""""""""""""""
Country:  |""""""""""""""""""""|
              """""""""""""""""""""
State: |""""""""""""""""""""""""|
          """""""""""""""""""""""""
Contacts: |"""""""""""""""""""""|
               """""""""""""""""""""
How You Can Help: |"""""""""""""""""""""""""""""""|
                            """""""""""""""""""""""""""""""
Why You Want Staff: |"""""""""""""""""""""""""""|
                              """""""""""""""""""""""""""
-----------------------------------------------------------------
Multiple Choice Questions:

What do you do if someone hacks?
[] Kick them and do nothing else
[] Immediately ban and IP ban them
[] Report it
[] Do nothing

What do you do if someone floods the chat?
[] Mute them
[] Kick them
[] Ban and IP ban them
[] Do nothing

What do you do if someone cusses someone else out?
[] Mute and kick them
[] Ban them
[] Report it
[] Do nothing

What do you do if someone reports someone else to you?
[] Ban the reported user
[] Do nothing
[] Report it to the owner
[] Ask for proof and take further action only if proof is given

---------------------------------------------------------------------------------

Refer to the |"""""""""""""""""""""""| as a box the user applying can write in.
                  """"""""""""""""""""""""
Refer to the |""""""""""""""""""""""| as a button for the user applying to click
                 |  Finish Application |                     when completed their
                 """"""""""""""""""""""""            application and it gets sent to me.

Refer to the [] as the little circles people click in the multiple choice (like if you do a poll there's multiple choices to click on, but this isn't a poll)

Thank you in advance.