Module, Pluging or something to do a simple task !

i need to do a Windows or box in my sitefinity website in the Right side to get the phones of my costumers to call back them when they need information... example inside a box put:

"we call you"

phone: (here the costumer put the phone number)

name:(here the costumer put the name)

"call" (when the costumer click on call the information goes to my email.

it`s all... i hope somebody can help me

i have the Sitefinity 7.0 version