Need to send out email from input from screen with attachment

I need to have somebody create a web application that does the following: 1) From input from a screen the user can enter information such as Email Address, Full Name, Project Name and 2 - 3 other text items. The program will then create an email and automatically send it to the recepient. It will attach a Word Doc. The Word doc will be a template that needs to filled out with some of the details from the input and automatically attached and send to the recipient. I would like this to be password protected so not anybody can get to this web application to send out the mails.