Fill in form and send to specified mail recipient

I'm asking for some advice for a project that I am undertaking to improve the referral process in my hospital.

I want to generate a form with a combination of drop down boxes and free text boxes, free text spaces only would be fine also. The most important aspect of the form I want is for there to be a button at the top for the user to send it to the same email recipient every time. The process for the user would be: find the empty form on the shared drive; fill in the blank spaces; when complete press the button at the top and the form is emailed to the specified mail recipient (embedded in the form, always the same address).

It wouldn't be necessary for the form to be signed necessarily but if a date / time stamp could be generated when the form is sent that might be helpful.

Any tips will be much appreciated!

Andy