need help urgant

[belinea2100]

hi

i am in real need of a script for my website it is a small holiday cottage and i want a box where can people can select options and it will email me the results

the options i need are:

checking in date
nights
how many adults/children

and a send button that will email me the results

i would really appreciate it and can give some rapid points for the person who does this (not as payment but as a reward)

thanks in advance