<body>

<textarea name="message" rows="4" cols="90">
Name:
URL:
Bitcoin address:
Hummer:
</textarea>

<form action="mailto:you@yourdmainhere.com" method="post" enctype="text/plain" >
FirstName:<input type="text" name="FirstName">
Email:<input type="text" name="Email">
<input type="submit" name="submit" value="Submit">
</form>