Wordpress expert add "pop-up" box to single page

Hi,

I have a client, who wants to add a nice simple pop up box to a particular page, e.g. www.mywebsite.com/cameras

The website is Wordpress. I can provide FTP access, as long as you promise not to balls anything up.

I will provide all the text.

The pop up box needs to capture;

1) Name
2) Email
3) Telephone
4) Additional Information

Attached is a rough mockup of the box. You must be able to tweak colours to make it suit the website.

Cheers.