185673 Need Simple database app!

I am in need of a simple web-based application where the attached form will be on a webpage and the fields that would normally be filled out by hand would have database fields. The description area will can be one big text box. Each form will be be saved as one record

I will need to be able to search for records based on the persons name (last)

Once the information is entered I need to be able to print this out on a preprinted form - I attached the form for layout purposes - it is 8 1/2 inches x 11 inches

I need this ASAP

I would need to install it on my server, so a simple database application would be fine, it can even be text based

Thank you

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