I'm new to forms, please help.

Hello,

I am very new to forms, I have never done one before.  What I want to do, I feel is VERY basic in form design, so if possible I'd appreciate step by step instructions.

I would like to use a normal e-mail, except make the body of the e-mail smaller and add in a few fields.

Fields I want to add to a normal e-mail.

1.)  Company Name  (text box)
2.)  Contact Name   (text box)
3.)  Contact Number   (text box)
4.)  Date customer cancelled with other carrier  (text box, but formatted for dates)
5.)  Who they spoke to  (text box)
6.)  Confirmation number for cancel   (text box)

and then the body of the e-mail, would be left for notes if needed.

I hope this makes sense.  I am just very unsure of how to pull this off. I am also unsure of what I have to do, in order for the person to recieve this, to see it as well.