I can has your personal details? django-ichypd is a simple django app that will allows you to show a form for a custom model that you provide and saves data into this model. After that a confirmation is shown. It also ships with some helpers for extracting this information as CSV to import it in your favourite CRM system or newsletter app.
ichypd is pronounced like egypt.
django-ichypd is in active development and still very young. Documentation will follow if it proofs useful.