Custom lockout page?

I’m wondering if it’s possible to have a custom lockout page.

For instance, if someone is locked out because they’re IP address is in the ban list, but that IP is a dynamic IP that a hacker was using to try to get it and has been reassigned to a different person, I would like to be able to give them the option of filling out a contact form to request the lockout be lifted.

Can this be done?

http://wordpress.org/extend/plugins/better-wp-security/