pop up plugin with a form to remove pop up

I am looking for a pop up plugin that will allow the following:

pop up to display on one specific page only.

either has form functionality or can use short code to display a form from another plugin

pop up will not be able to be removed (no X in corner or clicking on the background) the only way to remove it is to enter the form and press submit agreeing to the terms.

Can anyone recommend a plugin for this? Free or pay does not matter.

Thanks a lot.