How to create a basic SOAP request page

Question

I need to create a basic html page to capture some user information, First Name, Surname, value and email address and description of goods etc. This then needs to be sent to example.com as a basic SOAP request as (below)

this will be a simple signup form. User will manually input the data and on submit the information should pass to "http://www.example.com/". I want to know, How to create a HTML page to do the job.

<?xml version="1.0" encoding="utf-8"?>
<s:Envelope xmlns:s="http://schemas.xmlsoap.org/soap/envelope/">
<s:Body xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema">
<SubmitNewApplicationShort xmlns="http://www.example.com/">
  <newApplicationDataShort>
    <UserCredentials>
      <LoginName>xxxxx_icet1</LoginName>
      <Password>XXXXXXX</Password>
    </UserCredentials>
    <ProposalShort>
      <ClientReference>3692</ClientReference>
      <CashPrice>1700</CashPrice>
    </ProposalShort>
    <Goods Type="HI0">
      <Description>boiler</Description>
      <Quantity>1</Quantity>
    </Goods>
    <Customer>
      <Title>MR</Title>
      <Forename>TEST</Forename>
      <Initial xsi:nil="true" />
      <Surname>SIX</Surname>
      <EmailAddress>xxxxxxx@xxxxxx.com</EmailAddress>
    </Customer>
    <Address>
      <HouseNumber />
      <HouseName />
      <Flat />
      <Street />
      <District />
      <Town />
      <County />
      <Postcode />
    </Address>
  </newApplicationDataShort>
</SubmitNewApplicationShort>
 </s:Body>
 </s:Envelope>