diff --git a/src/components/InsertForm.js b/src/components/InsertForm.js
new file mode 100644
index 0000000..ec64d4c
--- /dev/null
+++ b/src/components/InsertForm.js
@@ -0,0 +1,121 @@
+import React, { Component } from 'react';
+import {
+  Row,
+  Col,
+  Form,
+  FormGroup,
+  Label,
+  Input,
+  Button
+} from 'reactstrap';
+
+class InsertForm extends Component {
+  constructor(props) {
+    super(props);
+
+    this.state = {};
+  }
+
+  render() {
+    return (
+      <div>
+        <Form onSubmit={this.props.handleSubmit}>
+          <Row form>
+            <Col md={6}>
+              <FormGroup>
+                <Label className="font-weight-bold" for="firstName">First Name</Label>
+                <Input
+                  name="firstName"
+                  type="text"
+                  value={this.props.firstName}
+                  onChange={this.props.handleInputChange}
+                  placeholder="Jon"
+                />
+              </FormGroup>
+            </Col>
+
+            <Col md={6}>
+              <FormGroup>
+                <Label className="font-weight-bold" for="lastName">Last Name</Label>
+                <Input
+                  name="lastName"
+                  type="text"
+                  value={this.props.lastName}
+                  onChange={this.props.handleInputChange}
+                  placeholder="Snow"
+                />
+              </FormGroup>
+            </Col>
+          </Row>
+          <Row form>
+            <Col md={12}>
+              <FormGroup>
+                <Label className="font-weight-bold" for="email">Email</Label>
+                <Input name="email"
+                  type="email"
+                  value={this.props.email}
+                  onChange={this.props.handleInputChange}
+                  placeholder="example@mail.com"
+                  />
+              </FormGroup>
+            </Col>
+          </Row>
+          <Row form>
+            <Col md={12}>
+              <FormGroup>
+                <Label className="font-weight-bold" for="type">Type</Label>
+                <Input
+                  name="type"
+                  type="select"
+                  value={this.props.type}
+                  onChange={this.props.handleInputChange} >
+                  <option value="">---</option>
+                  <option value="requestInformation">Request Information</option>
+                  <option value="technicalAssistant">Technical Assistant</option>
+                </Input>
+              </FormGroup>
+            </Col>
+          </Row>
+
+          <Row form>
+            <Col sm={12}>
+              <FormGroup>
+                <Label className="font-weight-bold" for="subject">Subject</Label>
+                <Input
+                  name="subject"
+                  type="text"
+                  value={this.props.subject}
+                  onChange={this.props.handleInputChange} 
+                  placeholder="Subject"
+                  />
+              </FormGroup>
+            </Col>
+          </Row>
+          <Row form>
+            <Col sm={12}>
+              <FormGroup>
+                <Label className="font-weight-bold" for="message">Message</Label>
+                <Input
+                  name="message"
+                  type="textarea"
+                  value={this.props.message}
+                  onChange={this.props.handleInputChange}
+                  placeholder="Message"
+                  />
+              </FormGroup>
+            </Col>
+          </Row>
+          <Row form>
+            <Col align="center" md={{ size: 8, offset: 2 }}>
+              <FormGroup>
+                <Button type="submit" color="primary">Open Ticket</Button>
+              </FormGroup>
+            </Col>
+          </Row>
+        </Form>
+      </div>
+    );
+  }
+}
+
+export default InsertForm;
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