This would take some coding which I recommend hiring a Shopify Expert to assist with though as an alternate, you may be able to achieve this with a custom form builder app.
This app - Email Popup | Email Marketing - allows you to create a sign-up form for collecting email addresses that also allows for additional input for the customer.
There are some great options like multiple choice:
The form is fully customizable to allow for your branding as well. Let me know what you think!
How are you finding the platform so far? It's great to see that you are making sure you have reach across multiple regions for your customers.
As far as marketing campaigns once you've established a sufficient email list, be sure to familiarize yourself with all of the easily integrated features and building tools found in Shopify Email.
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