The HTML:

  

   
<ul>
   
    <li id="menu-item-44" class="menu-item-44"><a href="">Feedback</a></li>
   
</ul>
  

Script:

  

   
    <script>
   
        jQuery(document).ready(function () {
   
            jQuery('.menu-item-44 a').click(function () {
   
                jQuery.blockUI({ message: ('<div id="feedback"><div style="background-color:#fff; padding:20px; border:2px solid #031e77; z-index:9999;"> <form method="POST"> <div>Submit your feedback! <a href="#" id="close"><img src="/wp-content/uploads/images/round_red_close.gif" style="float:right;"/>Close</a></div> <div style="clear:both;"></div> <table border="0" width="100%"> <div style="text-align:left; margin-top:5px;margin-bottom:15px;">Use this form to submit your comments and/or questions to the Assessor\'s Office. If you wish to change your address, please <a href="/change-of-address/">click here</a>.</div> <tr> <td colspan="2" style="text-align:left;"> <select name="feedback_type" id="feedback_type" style="width:97%;"> <option value="website">Website Feedback</option> <option value="website-error">Website Error</option> <option value="information">Request Further Information</option> </select> </td> </tr> <tr> <td colspan="2"><hr/></td> </tr> <tr> <td>First Name</td> <td style="text-align:right;"><input type="text" id="first_name" name="first_name" placeholder="Your first name"/></td> </tr> <tr> <td>Last Name</td> <td style="text-align:right;"><input type="text" id="last_name" name="last_name" placeholder="Your last name"/></td> </tr> <tr> <td>Email Address</td> <td style="text-align:right;"><input type="text" id="email_address" name="email_address" placeholder="Your email address"/></td> </tr> <tr> <td style="text-align:left;">Phone Number</td> <td style="text-align:right;"><input type="text" id="phone_number" name="phone_number" placeholder="Your phone number"/></td> </tr> <tr> <td colspan="2"><hr/></td> </tr> <tr> <td colspan="2" id="comments-row"><div>Comments</div><textarea id="comments" id="comments" style="width:97%; height:200px;"></textarea></td> </tr> <tr> <td colspan="2"> <div style="float:right;"><button type="reset" value="Reset" id="feedback_reset_button" name="feedback_reset_button">Reset</button><button type="button" value="Submit" id="feedback_submit_button" name="feedback_submit_button">Submit</button></div> </td> </tr> </table> </form> </div></div>') });
   
            });
   
            $('#close').click(function () {
   
                jQuery.unblockUI();
   
            });
   
        });
   
    </script>