diff --git a/src/components/extension-uninstall/Form.tsx b/src/components/extension-uninstall/Form.tsx
index 9d18ca833..1942b7fb6 100644
--- a/src/components/extension-uninstall/Form.tsx
+++ b/src/components/extension-uninstall/Form.tsx
@@ -48,9 +48,14 @@ const StyledForm = styled.form`
 
 const Form = () => {
     const [state, setState] = useState<{
+        name?: string
+        consent?: boolean
+        email?: string
         feedback: string
         otherFeedback?: string
         messageSent?: boolean
+        errorMessage?: string
+
     }>({
         feedback: ''
     })
@@ -78,9 +83,12 @@ const Form = () => {
         e.preventDefault()
 
         const email: Email = {
-            subject: 'Why did I uninstall the browser extension?',
-            feedback: state.feedback,
-            otherFeedback: state.otherFeedback
+            from: {
+                email: state.email,
+                name: state.name
+            },
+            subject: 'Why did I uninstall the browser extension?' + '  (from ' + state.email + ')',
+            message: state.feedback + state.otherFeedback
         }
 
         fetch('/.netlify/functions/submit-form', {
@@ -103,8 +111,20 @@ const Form = () => {
             onSubmit={handleSubmit}
         >
             {
-                !state.messageSent ? (
+                state.messageSent ? (
+                    <div className="sucess">
+                        <img src={tick} className="tick" alt="Tick" />
+                        <h3>Thanks for your Feedback</h3>
+                    </div>
+                ) : (
                 <>
+
+                    <div style={{ visibility: 'hidden' }}>
+                        <label>
+                            Don’t fill this out if you're human: <input name="bot-field" />
+                        </label>
+                    </div>
+
                     <input type="hidden" name="form-name" value="extension-deletion" />
                     <h3>Why did you uninstall the browser extension?</h3>
                     <p>Check all that apply:</p>
@@ -125,15 +145,53 @@ const Form = () => {
                             <input type="checkbox" onChange={handleChange} name="expected" data-text="Gitpod isn’t what I expected" />
                                 Gitpod isn’t what I expected
                         </label>
+
                         <textarea onChange={handleTextAreaChange} aria-label="Do you have any other feedback?" placeholder="Do you have any other feedback?" name="otherFeedback"></textarea>
+
+                                                <label className="visually-hidden" htmlFor="Name">
+                            {' '}
+                            Name
+                        </label>
+                        <input
+                            autoFocus
+                            name="name"
+                            className="form__input form__input--half"
+                            type="text"
+                            placeholder="Name"
+                            id="Name"
+                            onChange={handleChange}
+                        />
+                        <label className="visually-hidden" htmlFor="email">
+                            E-Mail
+                        </label>
+                        <input
+                            name="email"
+                            className="form__input form__input--half"
+                            type="email"
+                            placeholder="E-mail"
+                            id="email"
+                            onChange={handleChange}
+                        />
+
+                        <div style={{ display: 'flex', justifyContent: 'space-between', alignItems: 'baseline', margin: '0px 0px 20px 0px' }}>
+
+                            <input
+                                name="consent"
+                                id="consent"
+                                type="checkbox"
+                                onChange={handleChange}
+                                style={{ margin: '0px 10px', transform: 'translateY(.5rem)' }}
+                            />
+                            <label htmlFor="consent">
+                                I consent to having this website store my submitted information so that a support staff can respond to my inquiry.
+                            </label>
+                        </div>
+
+                        {state.errorMessage ? <p className="error">{state.errorMessage}</p> : null}
+
                         <button className="btn" disabled={!state.feedback && !state.otherFeedback}>Send</button>
                     </div>
-                </>) : (
-                <div className="sucess">
-                    <img src={tick} className="tick" alt="Tick" />
-                    <h3>Thanks for your Feedback</h3>
-                </div>
-                )
+                </>) 
             }
         </StyledForm>
     )