Send form mail, help

how can i put a fill box and make an PHP to send me the information, in this java script.

Code (JavaScript):

1. function OnMouseDown () {
2.    if(Input.GetMouseButtonDown(0))
3.     var url:String = "www.confidentialxcompany.com/appemail/appemail.php";
4.     var form:WWWForm = new WWWForm();
5.     form.AddField("companyname","companyname");
6.     form.AddField("siteaddress","siteaddress");
7.     var www:WWW = new WWW(url,form);
8.     Debug.Log("Sending mail");
9. }