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Help with Smart Send Workflow

Hello, I need help with a Smart Send workflow.  I'm currently doing this with a paper template, but I want to change it so that the user can do it from the Xerox machine itself and have the email be variable.    Here is what I want it to do:

 

I want the user to place a document in the hopper, have the machine prompt for their email address and have the document converted to MS Word and emailed to the user.

 

Can this be done?  If so, how?

 

Machine : Xerox workcenter 5755

Smart Send: V 2.1.50

 

Thanks!

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