Dynamic form that sends info to internal dolphin mail

Hello, 

I am looking for a dynamic form that each member, at a certain membership level can set up. The form can be used by anyone, not required to log in and can be used on a page with other blocks or info (picture, member level, etc).

That gets sent to internal dolphin mail system and option to send to email address as well.  

Seems like a modified mail.php could possibly work. 

Thanks for your time.

Benny