If you really wanted to, this exact information can be gathered (and emailed to a client) via the native EE Email Module Contact Form:
http://expressionengine.com/docs/modules/email/contact_form.html
However, you cannot create your own template with it. Freeform would allow you to do such.
Following the Freeform Form documentation, a sample code might look like this:
{exp:freeform:form form_name="choose_a_form_name" send_user_email="yes" user_email_template="some_template" notify="you@yourdomain.com" template="your_notification_template" return="my/template" required="name|email|comments"}
<p>Name<br />
<input type="text" name="name" value="{logged_in_screen_name}" />
</p>
<p>Email<br />
<input type="text" name="email" value="{logged_in_email}" />
</p>
<p>Comments<br />
<textarea name="comments" cols="50" rows="5"></textarea>
</p>
<p>
<input type="submit" name="submit" value="Submit" />
</p>
{/exp:freeform:form}
Make sure you create the “comments” field in the Freeform CP (I believe the name and email fields are there by default… maybe even the comments too).
Also, you will need to create two templates from the Freeform Templates CP
One will be from the parameter user_email_template=“some_template” which will be the template the user will get - name the template whatever you wish, and create it in the Freeform Templates CP. Just follow the steps, and then style the form the way you wish, using {name}, {email}, and {comments} as the variables submitted from the user from the Freeform form.
The other, template=“your_notification_template” is the template that will be sent to you, which would be created the same way as the other one above.
Let me know if you have any futher questions 
