is possable to do the following

[Task1]

Hi all

I was wondering if it is possable to do the following:
below is supose to be a single line of a site address but insted of fussing
around with the line
i would like to do somthing like (******)= an input value and [******]= a
dropdown menu
on a form of some sort......
is this possable

https://customer.hosting
.co.uk/addpack.cgi?authcode=69548963-raaaaaaHjUnx;email= siteaddress@
Domain.com;M_domain=(******);M_typeid=[******];status=Y

My Regards
Task1