Create a Page Template with a Form

Is there a way I can create a page template which contains a Perch Form that will allow the editor to create a new page and designate where the form sends the email too?

I want to allow the editor of the website the ability to add a new 'Service page' to their website, which has a Perch contact form at the bottom. However each 'Service' will have a different point of contact, hence the need to change where the form emails to.

Or is there a better way to do this that I am not seeing?