In a short time, using PHP and Symfony :
Create a form with this fields :
* First name
* Last name
On submit, the script generates a pdf file with this content :
From : ACME Corp
To : [First Name] [Last Name]
[ Address + ZipCode + City]
Thank you for your payment of [RANDOM AMOUNT between $1000 and $1000000] received on [last monday date]
The Customer Service team.
and with in the background a watermark with this file : http://www.office-supply-store.us/office/office-supply/188.8.131.52/Large/SCOS4008.JPG
The pdf file should be sent to the email address entered in the form. The from field should be "firstname.lastname@example.org".
Thanks and good luck !