[#84702440] WHSC form

![walkthrough](https://s3.amazonaws.com/f.cl.ly/items/3Y3l0x1b0Y073B341B3S/Screen%20Recording%202014-12-23%20at%2003.17%20AM.gif)

TODOs (which we can wait on to merge, or not):

* [ ] Decide if any other fields need to be added
* [ ] Decide how approvers should be specified
* [ ] Get emails working, even in a basic way

@ericadeahl This was a low-effort pass at styling, but would love any quick feedback on the design/layout.