Is this something of the sort of what you were looking for? Letterhead

Please note that this is a quick and dirty job and I only added the fields and did not change any of the wording at the top or do any tweaking. Dave's way of doing it is best and also more secure, but this may hold you over until you're able create a better one.

Also note that every ISP handles form mail differently and you would have to contact them or read their FAQ on what tags or code you have to add to make the form work and for the content to be emailed to you. You will also have to name the fields so you know what they are when you read the email. Lastly due to the info requested on the form, you may want to put it on a https, but sending personal and bank info through an email is not the best thing to do no matter if it is sent from a https or not.

The best way is the way Dave suggested. That way it could be hooked to a gateway and no personal info for it to send through email, but since they are printing it out and attaching it, this may hold you over until you can go with a more secure way. You do not want people sending an email with an attachment as this can be a quick way to get a virus. Feel free to save that page to your computer if you desire.