A small windows app to capture user input,and sysinfo data and HTTP post the data bac

General information for the business: We are a small IT support company
Kind of development: New program from scratch
Description of every module: The app needs to be a standlone exe. No installer.

Opening screen shows our logo.....and requests two piece of user information:

"Please enter the asset sticker ID of this computer" (text box - max length 4)
"Please enter a friendly name for this computer (e.g. John Wilson's Computer) (text box max length 20)
Description of requirements/functionality: Once the user data has been entered - the user presses "Submit".

The program then pipes the output from

ipconfig /all
and
systeminfo

The software will then do an HTTP post back to our web server with this data

e.g.

assetid=1234&friendlyname=toms computer&ipconfig=BLAHBLAH&systeminfo=BLAHBLAH
Specific technologies required: C++?? It must be a standlone app!
OS requirements: Windows
Extra notes: