255611 Report Broken/Deleted Form

i need a report broken script for my site which will be under every video(video site) and when someone clicks it ...it will first do a small spam check and then it will say a message(my desired message) then it will mail the URL and TITLE of the page to an email address. i hope it can be made quickly and it will be much better if u can do this as a plug-in in joomla 1.5 , to be displayed only in desired sections! but it doesnt have it be a joomla plugin.