49363 Contact / Schedule a Call Form

I'm looking to develop a "contact us" page where users can schedule a call from me. The form will include the contact information of the user as well as a list of dates and times to schedule a call. The date list should contain the next 10 business days. An example of this type of form is located at [login to view URL] . After a user submits their information, entries should be emailed to my email address.