This is a pretty nice little script. You can exchange the request for information to ask for just about anything you want. In the script, change out where it has the text asking for the domain.
Please note: This script is being offered in simple text format. When you click to Grab the Script, the text should display. Internet Explorer and AOL users may get a blank page or the script may run and produce the effect. If this happens, choose SAVE AS from the FILE menu and save the blank or compiled page.