Add a form to the identity-error page

[h-m-f-t]

Issue description

Users that aren't able to pass identify proofing by Login.gov are instructed to send us an email with certain information.

It would be a better experience for users if this were a form. It would also be great for the program to be able to track these requests in the registrar, in the same place new domain requests are managed. This also could allow for a more direct connection between verification requests and entries in verified_by_staff.

Acceptance criteria

• Determine the viability of adding a form that is hosted on get.gov but whose results are added to manage.get.gov.
• If determined to be viable, create additional issues (e.g., API on cisagov/manage.get.gov for form results; potential new table in registrar; design form)

Additional context

No response

Links to other issues

No response