Simple Front End Email Reminder Script or Wordpress Plugin/Widget

I need a simple script, plugin, or widget that will work on Wordpress to allow front end site visitors to send themselves an email reminder, at a preset date in the future. It will simply be composed of a form that has the following: 1) An email address entry blank 2) A product name blank 3) A product code entry blank 4) A drop down list of up to 10 preset numbers of days from present, to send the reminder. 5) Google Captcha 6) The code to make it work, and instructions for myself to install it, and edit the details as needed. It can use any common wordpress cron function, have a preset email "message", along with the data from the form, and must also send a copy to admin's email address, at the same time. A definite bonus would be if it could check a spreadsheet of list members, and ONLY send the reminder, if the email belongs to a member on that list.