<h1>Request Group Rate</h1>
<form>
    <input type="hidden" name="referrer">
    Name: <input type="text" id="fieldName" name="name"><br>
    Group size: <input type="text" name="groupSize"><br>
    Email: <input type="email" name="email"><br>
    <input type="submit" value="Submit">
</form>
<script>
    $(document).ready(function(){
        $('input[name="referrer"]').val(document.referrer);
    });
</script>