Simple form offline

URGENT - need this by 11AM GMT TODAY!! I need a basic input form with 4 inputs: Name, phone number, email, and age. When you submit, I want the form to write the output to a text file (in any format) on the local machine (A Windows computer) WHILE OFFLINE, i.e. no internet access. $30 for first person to do it correctly URGENT - need this by 11AM GMT TODAY!!