Adjust the code for the site

For the site: Texto oculto is required on the main page of the site,
To adjust the code that I will form on Texto oculto to form an application, so that in fact everything remains as it is (visually), only by clicking on the button "Get the results of the check", the customer got into the subscription list Texto oculto, and the application came to my address with the parameters that the client chose.

The reason for the request is that the application form for Texto oculto provides only 2 fields - name and email, this is not enough, and the design must also be adjusted for the site!