Is there a referral form plugin?

I am looking for a plugin that will allow me to have a visitor enter the following:

Their name
Their phone number
Their email address
Referred name
Referred phone number
Referred email address
Their referral message

The form needs to send their message in an email to the referred email address. Is there something like this available, or am I going to have to make one? Google has yielded no results that fit the bill. Thanks