Custom form for sending mail

Is it possible to create a custom Form which would have various functions:

1) possibly password protected or use Wordpress Authentication.
2) allow the form to create an email message which gets sent to an email that is input in one of the form fields.

Basically the idea is to allow writers to easily contact marketing departments via this form. The fields would be something like:

Marketing Dept Email
Contact Name
Product Name
URL

Then the form will send an email to the Market Dept Email, addressing them by name, requesting the Product Name and placing the URL somewhere neatly in that same message. The reply/sender address would not change, it would be something like media@ourcompany.com

Hope I explained that clearly? Any help or guidance would be greatly appreciated.

Thanks

Ok, got most of the form done. How do I create a field that includes the username of the wordpress user when they are logged in?