Sorry, I misunderstood your question.

You will have to write a (CGI-)script that dynamically generates the webpage on which is your form. CGI.pm is the archetypical module to do this, but there are many other solutions. Ovid's CGI-course (esp. lesson four and lesson six] will give you a lot of valuable pointers. Personally I tend to use now a templating solution (Template Toolkit) for anything but the most trivial applications, but YMMV.