构建一个表单字段来填充脚本中的行？

I have a short script that pulls information from a site called RPR. I was wondering if I can build a form for "Address" and have it fill out the "Query" line automatically on the next page?

<script type="text/javascript">
  var rprAvmWidgetOptions =
  {
    Token : "0596733F-54FC-4C23-89C8-8B021A6E486C",
    Query : "278 S 23rd St, Philadelphia, PA 19103",
    CoBrandCode : "btsusspaces",
    ShowRprLinks : true
  } 
</script>   

<script type="text/javascript" src="//www.narrpr.com/widgets/avm-widget/widget.ashx/script"></script>