The form and output are based on a few assumptions:
- that an individual is operating the blog / site;
- the site is externally hosted;
- you are operating an email subscription list that is managed by a third party service provider such as MailChimp;
- you’re using WordPress for your site;
- you accept comments; and
- you use Google Analytics for site statistics.
If these assumptions aren’t correct in your case, you may need to adapt the output.
Of course, I can’t say whether the output will necessarily cover all bases for you, given your own circumstances and the laws that may apply in your country, but hopefully it’ll provide a helpful starting point.