Assessment maker

Hello. I'm looking for a program that will allow me to enter multiple questions which the user would answer on a scale, then total up all the answers for that particular user and report on screen. (hosted on a website) An example: Complete the following questions where 0 is not true, 1 is somewhat true, 2 is mostly true, and 3 is always true: 1. I like apples __0 __1 ___2 ___3 2. I like pears ___0 ___1 ____2 ____3 3. I like grapes ___0 ___1 ____2 ____3 When the person clicks 1. 0, 2. 3, and 3. 2 to answer and clicks submit they receive a score of 5 which is emailed to them Here's an example: [login to view URL] I just need a template or something to allow me to type in the questions. Once I have the files I can upload them to my server.