You can create this contact form using Jetpack’s Contact Form modules.
[contact-form to=’admin@example.com’ subject=’Contact Form’][contact-field label=’Name’ type=’name’ required=’1’/][contact-field label=’Email’ type=’email’ required=’1’/][contact-field label=’Website’ type=’url’/][contact-field label=’Comment’ type=’textarea’ required=’1’/][contact-field label=’Are you a human?’ type=’checkbox’ required=’1’/][/contact-form]
