258011 Small php script needed

i need a quick little php script put together and thought i;d drop you a note to see if you can do this and for how much. i have an email I send out (one at a time..no spam here) and i would like a simple "form" that allows me to have a few variable areas. for example..: First part of the example sentence _________________ and then came the second part _____________________. Then we start the third part of the example ____________ and then the final ____________________. For the blanks in the above sentence I want to be able to input a keyword, the site name or url, the rank and the page for up to 10 different sites. so my input would look like this: blank 1 example: tomato press (this would be the keyword) blank 2 example: [login to view URL] [login to view URL] [login to view URL] [login to view URL] etc etc etc up to 10 sites blank 3 example: 1 2 3 4 5 6 etc etc etc (this would be the sites rank) blank 4 example: 2 3 4 5 6 7 etc 9 (this would be the page) after that, i need a form where i can just paste in the body of the letter since that could change from time to time. then, one more variable I have your contact info as: phone #. (just need a space to put in up to 10 phone numbers) then one more form area to paste in info to close out the letter. when thats all filled in, i need to push a button and have each of the ten letters typed out on a webpage so I can copy and paste...hope that makes sense! can you do this and if so, how much and when can it be delivered?