It could be done in an hour or at the most 2.. (depending on the full specs of the form (if you have the form alredy created it's quicker than hiring somone to do a form from scratch).
Figure $15-$50/hr depending on the person.
If you have the form already created, and just want the form results, and image emailed to you, I'd do it for $30.
Keep in mind there is a image size upload limit on Dreamhost, and from what i've read you can't get past that limit. (Different hosts have different limits).
I40.com - Home Page
MP3Mystic - Personal Streaming Music server.
(No longer hosted with Dreamhost)