Collecting emails in Rise

I have seen questions about sending an email in a Rise course. I am looking to do something a bit different. Perhaps there is a way to code it, but that's beyond my capabilities. I would like users to select which Canadian province/territory they are in (choose from a drop down of 12) and then enter their email address in a box. When they click submit, that information will be used to send their email address to the appropriate provincial admin person for follow up. Honestly, even if we could just do it with one contact email (instead of choosing from 12) that would work. But I don't see a way to do this. Thanks.

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