Not directly. The data would need to be within the form so it is really a question of HTML/javascript.

Perl could construct the page, including the form. CGI.pm discusses how you might do this.

You could also consider HTML::Template.

I would get the form working first, though, and then use either of the above to implement it. This would save having data hard coded into a static HTML page, which, I presume, you would rather avoid.