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Which edition of the Sales Cloud are you on ? There may be a couple of options depending on that.
Here is another smart idea: http://idealistconsulting.com/blog/creating-customized-stay-touch-request
The Form Assembly in there could even be replaced with FormSite.com(https://appexchange.salesforce.com/listingDetail?listingId=a0N30000001rmjpEAA) an another similar product! .