Simple offline program: input text write to DB

I have a computer that my users have access to (can walk up to it and touch it!). I want them to be able to enter their email address and name into a simple executable program or flash interface (again, this is all offline - local machine) and the software will record the data to a local file. Don't care about the database... The UI must have LARGE FONT INPUT FIELDS for name + email (should be visible from 3 meters) and on load grab an image file from the machine for use as its background image (Or an SWF if you can pull it off) Pretty simple stuff. Please bid $10 or lower... You can use whatever... Flash is welcome (especially if you can make the background nice - something wavy, etc. - or let me load my own)