Feedback Form on Individual Posts?

Okay, I’m using an install for a video site. So each post is a different video.

I’d love to have a form below each video where I could pose a simple question to the viewer, “What’s one thing you learned from this video,” or something similar that will just post to the backend where I can view it and review it.

Does anyone know of any plugins that will do this? Or possible some way to modify the comments action to do this? (Without posting the resulting response on the page)

Thoughts?

Thanks,

Nick