I think the simplest way to achieve this is to create a new form from scratch using standard html tags and linking it to a form processor such as the one supplied with forms-to-go (
http://www.bebosoft.com/products/formstogo/). You can link said form to a database query to populate the right fields, blend it in with some CSS, add a captcha and looks very professional in the process.
This is in fact on the very very very long to-do list for my site.
