Desktop simple email form application

We require a simple desktop email form application that will allow for static details to be entered Vessel Name Vessel IMO GRT Destination Email Address (The above data can not be altered by the user.) Once this has been fixed this application can then be sent by email for the user to save on their desk top. The desktop icon should give the user an application window that looks like the attached file. The reset of the form is not essential requirement as this could be done by our administrators and sent again to the user. This form must work independently form any other email application. The email format recieved must be comma deliminated and text based. Any questions let me know!!