Write some Software - Simple PC App form to MySQL (3 fields only) W7 and above

I want a simple form in an .exe distributable package. the app must have the ability to set host, dbname, dbusername, dbpassword etc for the mySQL connection (This must be stored for future use). The form will then contain 3 text fields to be sent to the mySQL table (two from a user stored preset value) and the third from a barcode scanner input. So to summarize. We have a settings menu with a total of 6 fields and a single front end bar code field. This information will be sent to update a mySQL on a successful scan. i.e. once the program is running there should be no user hands on, just a scan! Finally, it should look pretty!!!