I was wondering if there is a mod or anyone knows how I would go about this.

I have a product that is free, it is a diagnostic service, I was wondering if there is anyway to add on the product page a short order form that maybe would have just:

Name:
Number:
Email:
Address:

The customer would fill this out and hit submit and this would generate and order the back side.

Let me know if this is doable or if someone knows how and is willing to help me out.

Thanks