Looking for send (recommend) page script

Dear Friends,

I am looking for a Java script or Cgi script, which can take comments and 5 to 6 e-mail addresses, entered by the visitor. Then on click of a button the comments written by the visitor would be e-mailed to the addresses he has entered plus a copy of the message would get e-mailed to me for my reference. 

Does anyone know where I can find such a script????

Await your replies.

Best Wishes,
Sunil.
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