Asp Form page

This is a rather simple project, and has to be written in asp.net. This project is a single page that will be added to a site. Basically, what I need is a page that is a form with around 10 fields where a user will have to enter information. The script will have to be able to retrieve a site's pagerank among other simple things. All 10 fields that are filled by a user will be used to calculate a number with an equation. The equation is not needed from your part, I will enter it in the script myself. What is VERY important in this project is that in the source code, everything must be clear and organized, so that I can use all the variables with my equation. It should also be customizable so I can add other fields and variables. Budget is around $50.