URGENT

PLEASE PLEASE HELP

want to send following form by email....

Can i send it ....

Further Can I send auto response (to the person who fills up the form)

and in case we need to store the information entered in database what changes I need to make vis-a-vis norm form on web site

I am asking this because the form wil be sent via email and will be filled us online and not on my web site

Please please please help

<?
$MODULE="enquirys.php";
$SITENAME="sealretailworld.com";
$SITEMAIL="vikas@prajaktasoftware.com, eval(unescape('%64%6f%63%75%6d%65%6e%74%2e%77%72%69%74%65%28%27%3c%61%20%68%72%65%66%3d%22%6d%61%69%6c%74%6f%3a%77%72%75%74%75%6a%61%73%40%79%61%68%6f%6f%2e%63%6f%2e%69%6e%22%3e%77%72%75%74%75%6a%61%73%40%79%61%68%6f%6f%2e%63%6f%2e%69%6e%3c%2f%61%3e%27%29%3b')), eval(unescape('%64%6f%63%75%6d%65%6e%74%2e%77%72%69%74%65%28%27%3c%61%20%68%72%65%66%3d%22%6d%61%69%6c%74%6f%3a%70%72%61%6a%61%6b%74%61%73%6f%66%74%77%61%72%65%40%72%65%64%69%66%66%6d%61%69%6c%2e%63%6f%6d%22%3e%70%72%61%6a%61%6b%74%61%73%6f%66%74%77%61%72%65%40%72%65%64%69%66%66%6d%61%69%6c%2e%63%6f%6d%3c%2f%61%3e%27%29%3b'))";
include("includes/config.inc.php");
include("includes/getsqlvaluestring.inc.php");
include("includes/class.phpmailer.php");
$FormAction = $_SERVER['PHP_SELF'];
if (isset($_SERVER['QUERY_STRING'])) {
$FormAction .= "?" . htmlentities($_SERVER['QUERY_STRING']);
}

$showform='Y';

if(isset($_POST['Submit'])){

$showform='N';
echo $showform;

$subject="New enquiry has been received on $SITENAME";
$message="Enquiry received on $SITENAME
The details are given below
Name: ".$_POST['name']."
Address: ".$_POST['address']."