115774 Need email form created

I need a form similar to this: [login to view URL] I have some field modifications. On the top of the form, we have the following fields: "TAG REP" "TAG Invoice" "Company Name" "Company PO" "Date Purchased" "Reason for Return" Then the same bottom fields ("List You RMA Items") as this form. Once the user submits, I'd like to have an email generated with the information to send in email format.