Add Form and Upload to Site

I have a form that needs to be filled out online and emailed to me, also along with that form I need an attachment that the user uploads and also emailed to me. If there is no attachment, the form cannot be submitted and all fields of the form are required.

The site framework is CakePHP.

When the form is emailed to me it has to be printable and look exactly like the form I have attached.

Here is what I would like the pop up to look like. There will be some changes this is just an example.