simplified create ticket form

I am looking for a simplified create ticket form. name, email, subject, detail. All other items would have defaulted. No other text/images/logos surrounding the form. No login required. no login required.

i.e. what I am looking for is:
1) from the submitter’s standpoint is a simple contact/request form
2) from the agent’s standpoint a ticketing system.

Is this possible?

Thanks in advance for your time.