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Create two textareas, one for create a form template and other for a mail template.
The first one can be included on any page(s)/post(s)/sidebar. The advantage of this methos is have all control on your form. PHP tags will be scaped.
The second textarea determines a template mail that the form. On the template you can use [names] to put your content anywhere.
Sample:
This email was send by [name]
---
[message]
Screenshots
List of templates. See, your short tag is generated, you just need to Ctrl+c and Ctrl+v on yor post/tag.
Edit your form template.
Put your template form on your post.
You can change the reciver mail, passing the mail algument.
You can put the form on your templates, using the simple wpHardMailer function.