clone of magic video player

We need an optin script at the end of our videos, like on magic video player, <[login to view URL]>.? We need a title, and want to capture name and email address, with submit buttom,? and possibly an active link under it all.? We want to be able to add this to all of the videos we are producing for massive web distribution.? Would like the end product to be an flv file format.