Significant progress, but a long way from finished.

resources/templates/call-me.html

@@ -0,0 +1,37 @@
+{% extends "base-unauthenticated.html" %}
+{% block big-links %}
+      <div id="back-link-container">
+        <a href="javascript:history.back()" id="back-link">Back</a>
+      </div>
+{% endblock %}
+{% block content %}
+      <p>
+        Use this form to request someone to phone you to discuss your concerns about independence.
+      </p>
+      <form action="call-me" method="post">
+        <p class="widget">
+          <label for="name">Your name</label>
+          <input type="text" id="name" name="name"/>
+        </p>
+        <p class="widget">
+          <label for="postcode">Your post-code</label>
+          <input type="text" id="postcode" name="postcode"/>
+        </p>
+        <p class="widget">
+          <label for="phone">Your phone number</label>
+          <input type="text" id="phone" name="phone"/>
+        </p>
+        <p class="widget">
+          <label for="concern">Your concerns</label>
+          <select name="concern" id="concern">
+            {% for concern in concerns %}
+            <option>{{concern.title}}</option>
+            {% endfor %}
+          </select>
+        </p>
+        <p class="widget">
+          <label for="submit">&nbsp;</label>
+          <input name="submit" id="submit" type="submit" class="action" value="Call me!"/>
+        </p>
+      </form>
+{% endblock %}