Google Docs has a useful (and brilliantly implemented) feature that generates an HTML form for people to fill in, with the results saved as a row in the spreadsheet.
If you create a new spreadsheet, switch to the 'Form' tab and click 'Create a form', you can add questions in a variety of different forms (text, multiple choice, checkbox, etc). Once the form is saved, you can visit the live form, where you'll notice that it's just a standard HTML form: there are no form tokens or anything preventing you from altering the appearance of the form or even submitting the values directly from a server-side script.
One possibility is to use MaxMind's free GeoLite City database and API libraries to convert a visitor's IP address to a lat/long pair, address and country code, prefill this in the form as hidden fields, then use Google's map visualisation widget to display the results on a map.
Examples:
- Spreadsheet
- Form
- Modified form (note: haven't got GeoIP working on this server yet, so it's using dummy values).