So, you need a customized contact form on a page within a Wild Apricot hosted web site? Your options are very limited using Wild Apricot at this time, so you’re probably looking at a plug-in that you can use some plug in code as a Snippet to build the form.
Fortunately, there are a lot of options for this. We’ve used a few, but the one I will recommend for now is EmailMeForm. I don’t really believe that the cost should be significant for this kind of subscription service, and EmailMeForm is as reasonably priced as they come, with a limited free version and a $9.95 per month version that should cover most Wild Apricot contact form needs.