Service Area widget

[jbc]

I've looked everywhere and thought I'd try here. I need a simple widget that allows potential customers to enter their zip code and have one of three things happen:

If input of zip code is within a given number range (range 1), the visitor gets an input form to ask for a quote from sales rep 1

If input of zip code is within a given number range (range 2), the visitor gets an input form to ask for a quote from sales rep 2

If input of zip code is outside of range 1 or 2, the visitor gets a message display stating that we are sorry but we do not service their area.

Can anyone help me