Save this as form.php
<?php
if($_GET['action'] == "send") {
$Name = $_POST["Name"];
$Request = $_POST["Request"];
$Send = fopen("submitted.txt", "r+");
fputs($Send , "Name: $Name/n");
fputs($Send , "Request: $Request/n/n");
fclose($Send);
echo "Your message has been sent.";
exit();
?>
<form method="post" action="?action=send">
<table width="95%">
<tr><td width="200">Name:</td>
<td><input type="text" style="width: 300px;" name="Name"></td></tr>
<tr><td>Request:</td>
<td><textarea name="Request" style="width: 300px; height: 200px;"></textarea></td></tr>
<tr><td></td><td><br>
<input type="submit" value="Send!">
</td></tr>
</table>
</form>
Then make a blank file called submitted.txt
Then to add the form to a page use this code:
<?php
include("form.php");
?>