Kiosk Application for Andriod Tablet Devices

I need an application developed for attendees to fill out during a convention vising my booth. Currently I have an Adobe Air application that runs on my PC but I want to have something similar to run on an Android Tablet 2.1 The application should ask the user to fill out: - first name - last name - email - phone - address - city - state - zipcode At the bottom, it should include a three check-box: - I accept Terms of Condition - Add to email list - Add to SMS marketing Once the user fills out the form, the user click submit and the application says thanks you and maybe show an ad and start over for next user. The application should run all the time and not easily closed. The data should be stored in a database or something similar that I can export. I would need this application fast. Deadline is May 23.