This is a simple feedback form - but the entire setup ist built with AngularJS and WebAPI.
I'll write more about it in a blog series in January 2015, but for now you can just download the App and try it yourself.
Note that this is just showing the end-user form. The additional admin-page is hidden, since it wouldn't work without edit-permissions.
Thank you for your feedback. We'll get back to you as soon as possible.