I found this question about BugzScout which makes it sound like exactly what I need, but I can't find any public info about what fields /scoutSubmit.asp actually takes.
I have a hosted account, so I (think?) I don't have access to the files mentioned in the section labelled "How Do I Get This Working With FogBUGZ?" on the page linked from the above question for more info. Even just having access to the scoutsample.html mentioned on that page would more than likely be fine.