Urgent Help!

I would like to make, something which im not sure how to do. I have a form, which is the picture attached. I need to create it somehow with text fields for each option, and the text written needs to be sent to an email address. I need the format in the email to be something like this [but the person who enters the info must not have to go through any email stages]

Driver : [what they write]
Date : [what they write]
Address : [what they write]

etc etc, can anyone help me!

[type this in browser]

http://uk.geocities.com/mattdempsey@btinternet.com/form1.jpg

Matt