I want to start by apologizing for the delay in my response! While Constant Contact does not directly provide the code for a form like this, it may be possible to use a form designer tool if you are on a platform that is integrated with Constant Contact. For example, the Constant Contact for Wordpress plugin provides tools for creaitng forms.
I often find that forms that are designed by this have often been modified by a web designer to have a specific look. If you are interested in potentially hiring someone to create a custom form for your website you can find information about developers who work with Constant Contact here: http://marketplace.constantcontact.com/ServicesSearch?sort=rating&need=Software+Development
If there is any more information that I can provide, please let me know!