form or program creation

I am not tech-savvy and don't know the correct wording - so my apologies. I need a (form/program?) created. It will allow the user to type in a name, date of birth, time of birth, and place of birth. Then the user will input numbers (they have calculated themselves) into the provided spaces (9) on a grid-style design. it will automatically allocate the correct information to that number. There will be 9 sections - with 12 alternative answers. The end result is a custom report able to be seen on the screen or able to be downloaded or emailed to them. .