Image populator. Budget £70

I have a budget of £70GBP. I require 1. A simple form that captures a clients business information. Form will collect company name, company address, company telephone, client name and focus keyword. 2. Image (attached) gets populated with simple client information provided on form in the position A of the maps section. 3. Search box in image gets populated with Focus Keyword provided on form. 3. Uses our sendgrid account (smtp server) to send this as an email to client I have attached the image that needs to be populated to this project request. Email settings can be in a seperate text file. Email message can be in a seperat text file. No need for fancy admin panels. The email should include information that was submitted on the form. All the magic should happen with one mouse click and form information filled in. So for example the email will say Hi <client-name> Please find attached an image of what your business, <business-name>, would look like with a Google maps listing at position A on the maps. Kind regards John