Callback Request Button and Modal Form for Callback Request Zen Cart Header

This is a screenshot of our webpage at the moment: [login to view URL] We want to add a modal popup form for a callback request, sort of like this: [login to view URL] When the new button is clicked it should black out the background and a popup should appear like this: [login to view URL] For the "Contact Date" and "Contact Time" drop downs, we'd like them to pick up the dates automaticaly, like this site: [login to view URL]