This should be a contact
pop-up form with fields to fill out, and two buttons "submit" and "cancel".
The top of the form says
How can we help you?
The pop-up form collects the following information:
When the user clicks "Submit" the email address is checked for the
right format (e.g., must contain an asterisk).
If the email address is bad,
an error message is shown and the form does not close.
If the email address is acceptable,
the form information is stored in a database with a timestamp, and
the contents of the form are
sent to the email address: email@example.com
- Name (required, up to 50 characters)
- Email address (required, up to 50 characters)
- school (up to 100 characters, optional)
- city (up to 40 characters, optional)
- state (up to 20 characters, optional)
- message (up to 400 characters, optional)