How to have visitors input custom fields into a template script

I have looked everywhere trying to find a solution to this question, if someone could point me to a link, plugin that will help or maybe someone has an answer for me.

I would like visitors to be able to put their own words into blanks with a template script on a page in my wordpress website. for example:

My name is ____________ and I am ____ years old.

(the visitor would fill in the empty blanks or fields)

After the visitor fills in the blanks and clicks “submit” the next page would show the completed custom script:

My name is Charles and I am 41 years old.

Thank you!