Outlook macro form button

I need a macro button to be placed within Outlook, referred to as "sales lead" button.

When the send to : part is filled in with the persons name automatically with the generic message similar to the one within the example.

the user should be able to press the button and create the following form within outlook.

Within the example

1) Purpose of lead - should be a drop down menu which should include:
"new purchase",
"existing extension",
"New oppurtunities"

Once selected this should reflect within the subject line also. So the user does not have to type it again

2) Customers name: this should also reflect within the subject line once entered similar to that of the example

3) Customers account no: should also reflect within the subject line automatically similar to the example

The max i want to pay for this is £50