Ajax Questionnaire (11 Questions) 2

I need a Javascript (AJAX) questionnaire to run inside a Drupal article. The questionnaire would determine the user next action based on some simple questions (1 string, 1 integer, 9 binary). I would like the answer to be shown automatically without the need to reload the page.
It will be published in a Drupal 7 site as an article/story, so it should be compatible with that.

The questionnaire is that:

email ? [string]
age ? [integer]
hypertension ? [yes/no]
coronary artery disease ? [yes/no]
smoking ? [yes/no]
hyperlipidemia ? [yes/no]

If age >= 65 and “yes” to 3 risk factor then “need to do screening exam”

Head and neck cancer treated with irradiation ? [yes/no]

if “yes” then “need to do screening exam”

Did you had a stroke ? [yes/no]
Did you had a retinal artery ischemic event ? [yes/no]
have you already been carotid operated ? [yes/no]
Do you have peripheral vascular disease symptomatic ? [yes/no]

if “yes” then “need to do screening exam”

If does not get “need to do screening exam” then “Do not need to do screening exam”

So there are to end possibilities:
“need to do screening exam”
and
“Do not need to do screening exam”

Each one will have a different explanation text that should be shown (in HTML)

The email should be added to my MailChimp email list account. I use mailchimp plugin (http://drupal.org/project/mailchimp), so the API is already integrated in drupal environment, it should be easy to add it.

1.Please ask all you need before I accept your bid
2.I want a zip file with all source files for backup.
3.The questionnaire should be in portuguese (no problem, I can translate it later, just need to be able to do that)

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