Is it possible to create a call to action with form fields

Hi,

Can you advise is it possible to create a full width call to action that includes some text, and two form fields with text inside the fields entitled 'Your E-Mail' and 'Your Postcode' along with a SEND button in a horizontal row. Basically when the user clicks on the send button the content of the fields is e-mailed. 

Regards,

AWJ

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