Custom automatic form filling script required

It is basically for automation of from filling [login to view URL] bot should able to log-in to a pre defined one particular website and fill up the form (given an input once) for a pre-defined number of times and submit. The input will be changed manually by us. I do not mind any language/system as long as the code works for [login to view URL] script should be hosted online and can be accessed by the admin through internet through a password. For the exact nature of work,please refer the attachment which has [login to view URL] free to ask for clarifications.