Maybe something like this, using an email address:

The form element

<form_action="cgi-bin/upload.cgi" method="post" enctype="multipart/for
+m-data">
[download]

The form field

<p>Your email address: <input type="text" name="email_address" /></p>
[download]

The submit button

<p><input type="submit" name="Submit" value="Submit Form" /></p>
[download]