Email Script Needed

I need an HTML form that will generate an email (and send it out ) dependent on the inserted form fields. Basically, we are trying to automate our follow-up emails to our clients, but we need to personalize each one. I want my admin to be able to go to a link, fill out the required fields and send out that email. The script must recall the inserted data and the output must be in an email (see attached) I've created a fake form online to demonstrate what I am needing: [login to view URL] I want a form similar to this (note the conditional fields - coordinator, coordinator email and type) and I need the output to be in email form similar to the attached document. I hope I was able to clearly explain what I need. Please feel free to ask any questions!