How to add a custom field to a form, so that it addresses the person already?

Hi WPMU Dev team - I want to add a custom field that draws the NAME of the page to a form. For instance, http://hausie.com/in-trigue/, when you click "Request a Call" I need it to say You are requesting a call with the head designer of |Custom Field Value|. This |Custom Field Value| is basically the page name. Is this possible? (Also, when admin received the form I should know who this call request is for). Please help!