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Survey and/or Contact Form Integration...

I have not seen this type of question yet, so -


I was wondering if there was any way to Create a Feature that would

allow for us asking our visitors questions during the video?  Including

their Name & Email (for example)... 


This would be using "Yes"/"No" type questions  or  actual "Fields"

filled in, and/or possibly "Drop-Down Boxes", "Check Boxes" or "Radio

Buttons"


AND, being able to have the system :


(A)  Send me an email with their answers?


(B)  Possibly Integrate with a List Service(s) to allow the visitors Name

and Email (if used) to be sent/updated in my list service?


Thanks


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