email form page

Please see attached graphic. I require a web form which must send emails to specific receipients. A web page that we will use in an intranet. It consists of a few fields, and the ability to send the message to specific set of users. Please see attached graphic. There is no need for a database for this. Our server runs on php. 1) needs to look like my graphic (ie. rounded corner fields, logo, & send button) 2) All fields are mandatory (error popup if nothing is filled in 3) When chosing the receipient, the message must be emailed to the specific receipient. Ability to select more then 1 receipient (tick boxes) 4) Each receipient has his own existing email address, i need to be able to easily edit email addresses & also be able to add more receipients. You can either create a CMS for this, or show me how to edit the code) 5) The receipient should get the full message as well as subject & from fields.