diff --git a/src/app/services/tasksApi.ts b/src/app/services/tasksApi.ts
index 5cd678f48..4cab3fce2 100644
--- a/src/app/services/tasksApi.ts
+++ b/src/app/services/tasksApi.ts
@@ -3,6 +3,8 @@ import task, {
     TasksResponseType,
     GetAllTaskParamType,
     ExtensionRequestsResponse,
+    ExtensionRequestCreatePayload,
+    ExtensionRequestCreateResponse,
 } from '@/interfaces/task.type';
 import { api } from './api';
 import { MINE_TASKS_URL, TASKS_URL } from '@/constants/url';
@@ -114,6 +116,21 @@ export const tasksApi = api.injectEndpoints({
             }),
             providesTags: ['Extension_Requests'],
         }),
+        createExtensionRequest: builder.mutation<
+            ExtensionRequestCreateResponse,
+            ExtensionRequestCreatePayload & { dev?: boolean }
+        >({
+            query: (payload) => ({
+                url: '/extension-requests',
+                method: 'POST',
+                params: { dev: payload.dev ?? true },
+                body: (() => {
+                    const { dev, ...requestPayload } = payload;
+                    return requestPayload;
+                })(),
+            }),
+            invalidatesTags: ['Extension_Requests'],
+        }),
     }),
     overrideExisting: true,
 });
@@ -125,4 +142,5 @@ export const {
     useUpdateTaskMutation,
     useUpdateSelfTaskMutation,
     useGetSelfExtensionRequestsQuery,
+    useCreateExtensionRequestMutation,
 } = tasksApi;
diff --git a/src/components/ExtensionRequest/ExtensionRequestForm.tsx b/src/components/ExtensionRequest/ExtensionRequestForm.tsx
new file mode 100644
index 000000000..c41d941ce
--- /dev/null
+++ b/src/components/ExtensionRequest/ExtensionRequestForm.tsx
@@ -0,0 +1,216 @@
+import React, { useState, useEffect } from 'react';
+import styles from './Form.module.scss';
+import { useCreateExtensionRequestMutation } from '@/app/services/tasksApi';
+import { toast, ToastTypes } from '@/helperFunctions/toast';
+import {
+    EXTENSION_REQUEST_SUCCESS_MESSAGE,
+    EXTENSION_REQUEST_ERROR_MESSAGE,
+} from '@/constants/constants';
+
+interface ExtensionRequestFormProps {
+    isOpen: boolean;
+    onClose: () => void;
+    taskId: string;
+    assignee: string;
+    oldEndsOn: number | null;
+}
+
+interface FormData {
+    reason: string;
+    newEndsOn: number;
+    title: string;
+}
+
+const { SUCCESS, ERROR } = ToastTypes;
+
+const formatDateForInput = (timestamp: number) =>
+    new Date(timestamp).toISOString().slice(0, 16);
+
+const getOldEndsOnDate = (oldEndsOn: number | null) =>
+    oldEndsOn
+        ? new Date(oldEndsOn).toLocaleDateString('en-US', {
+              month: 'numeric',
+              day: 'numeric',
+              year: 'numeric',
+              hour: 'numeric',
+              minute: 'numeric',
+              second: 'numeric',
+              hour12: true,
+          })
+        : 'Not available';
+
+export function ExtensionRequestForm({
+    isOpen,
+    onClose,
+    taskId,
+    assignee,
+    oldEndsOn,
+}: ExtensionRequestFormProps) {
+    const [formData, setFormData] = useState<FormData>({
+        reason: '',
+        newEndsOn: new Date().getTime(),
+        title: '',
+    });
+
+    const [etaError, setEtaError] = useState(false);
+    const [createExtensionRequest, { isLoading }] =
+        useCreateExtensionRequestMutation();
+
+    useEffect(() => {
+        if (isOpen) {
+            const defaultNewEndsOn = oldEndsOn
+                ? oldEndsOn + 3 * 24 * 60 * 60 * 1000
+                : new Date().getTime();
+            setFormData((prev) => ({ ...prev, newEndsOn: defaultNewEndsOn }));
+            setEtaError(false);
+        }
+    }, [isOpen, oldEndsOn]);
+
+    const handleChange = (
+        e: React.ChangeEvent<HTMLInputElement | HTMLTextAreaElement>
+    ) => {
+        const { name, value } = e.target;
+
+        if (name === 'newEndsOn') {
+            const timestamp = new Date(value).getTime();
+            setFormData((prev) => ({ ...prev, [name]: timestamp }));
+
+            if (oldEndsOn && timestamp <= oldEndsOn) {
+                setEtaError(true);
+            } else {
+                setEtaError(false);
+            }
+        } else {
+            setFormData((prev) => ({ ...prev, [name]: value }));
+        }
+    };
+
+    const handleSubmit = async (e: React.FormEvent) => {
+        e.preventDefault();
+
+        const submissionOldEndsOn = oldEndsOn || new Date().getTime();
+
+        try {
+            await createExtensionRequest({
+                assignee: assignee,
+                newEndsOn: Math.floor(formData.newEndsOn / 1000),
+                oldEndsOn: submissionOldEndsOn,
+                reason: formData.reason,
+                status: 'PENDING',
+                taskId,
+                title: formData.title,
+                dev: true,
+            }).unwrap();
+
+            toast(SUCCESS, EXTENSION_REQUEST_SUCCESS_MESSAGE);
+            onClose();
+        } catch (error: any) {
+            toast(
+                ERROR,
+                error?.data?.message ?? EXTENSION_REQUEST_ERROR_MESSAGE
+            );
+        }
+    };
+
+    if (!isOpen) return null;
+
+    const oldEndsOnDate = getOldEndsOnDate(oldEndsOn);
+
+    return (
+        <div className={styles.modalOverlay} data-testid="extension-form-modal">
+            <div className={styles.modalContent}>
+                <h2 className={styles.heading} data-testid="form-heading">
+                    Extension Request Form
+                </h2>
+                <form onSubmit={handleSubmit} data-testid="extension-form">
+                    <div className={styles.formGroup}>
+                        <label className={styles.label} htmlFor="reason">
+                            Reason
+                        </label>
+                        <textarea
+                            id="reason"
+                            name="reason"
+                            value={formData.reason}
+                            onChange={handleChange}
+                            rows={4}
+                            className={styles.textArea}
+                            required
+                            disabled={isLoading}
+                            data-testid="reason-input"
+                        />
+                    </div>
+
+                    <div className={styles.formGroup}>
+                        <div className={styles.oldEta} data-testid="old-eta">
+                            Old ETA - {oldEndsOnDate}
+                            {etaError && (
+                                <p
+                                    className={styles.errorText}
+                                    data-testid="eta-error"
+                                >
+                                    Please choose ETA greater than old ETA.
+                                </p>
+                            )}
+                        </div>
+                    </div>
+
+                    <div className={styles.formGroup}>
+                        <label className={styles.label} htmlFor="newEndsOn">
+                            New ETA
+                        </label>
+                        <input
+                            type="datetime-local"
+                            id="newEndsOn"
+                            name="newEndsOn"
+                            value={formatDateForInput(formData.newEndsOn)}
+                            onChange={handleChange}
+                            className={`${styles.input} ${styles.dateTimeInput}`}
+                            required
+                            disabled={isLoading}
+                            data-testid="new-eta-input"
+                        />
+                    </div>
+
+                    <div className={styles.formGroup}>
+                        <label className={styles.label} htmlFor="title">
+                            Title
+                        </label>
+                        <textarea
+                            id="title"
+                            name="title"
+                            value={formData.title}
+                            onChange={handleChange}
+                            rows={3}
+                            className={styles.textArea}
+                            required
+                            disabled={isLoading}
+                            data-testid="title-input"
+                        />
+                    </div>
+
+                    <div className={styles.formActions}>
+                        <button
+                            type="button"
+                            className={styles.cancelBtn}
+                            onClick={onClose}
+                            disabled={isLoading}
+                            data-testid="cancel-button"
+                        >
+                            Cancel
+                        </button>
+                        <button
+                            type="submit"
+                            className={`${styles.submitBtn} ${
+                                isLoading || etaError ? styles.disabledBtn : ''
+                            }`}
+                            disabled={isLoading || etaError}
+                            data-testid="submit-button"
+                        >
+                            Submit
+                        </button>
+                    </div>
+                </form>
+            </div>
+        </div>
+    );
+}
diff --git a/src/components/ExtensionRequest/ExtensionStatusModal.tsx b/src/components/ExtensionRequest/ExtensionStatusModal.tsx
index 516ee89ac..640badc74 100644
--- a/src/components/ExtensionRequest/ExtensionStatusModal.tsx
+++ b/src/components/ExtensionRequest/ExtensionStatusModal.tsx
@@ -1,10 +1,11 @@
-import React, { useRef, useEffect } from 'react';
+import React, { useRef, useEffect, useState } from 'react';
 import styles from './ExtensionStatusModal.module.scss';
 import { useGetSelfExtensionRequestsQuery } from '@/app/services/tasksApi';
 import { SmallSpinner } from '../tasks/card/SmallSpinner';
 import moment from 'moment';
 import { ExtensionRequestDetails } from './ExtensionRequestDetails';
 import { ExtensionRequest, ExtensionDetailItem } from '@/interfaces/task.type';
+import { ExtensionRequestForm } from './ExtensionRequestForm';
 
 type ExtensionStatusModalProps = {
     isOpen: boolean;
@@ -84,6 +85,8 @@ export function ExtensionStatusModal({
         { skip: !isOpen }
     );
     const modalRef = useRef<HTMLDivElement>(null);
+    const [isRequestFormOpen, setIsRequestFormOpen] = useState(false);
+    const [oldEndsOn, setOldEndsOn] = useState<number | null>(null);
 
     const extensionRequests = data?.allExtensionRequests ?? [];
     const hasPendingRequest = extensionRequests.some(
@@ -105,13 +108,49 @@ export function ExtensionStatusModal({
         };
     }, [isOpen, onClose]);
 
+    useEffect(() => {
+        if (isOpen && (data?.allExtensionRequests ?? []).length > 0) {
+            const latestRequest = [...(data?.allExtensionRequests ?? [])].sort(
+                (a, b) => b.requestNumber - a.requestNumber
+            )[0];
+
+            const timestampMs =
+                latestRequest.newEndsOn < 1e12
+                    ? latestRequest.newEndsOn * 1000
+                    : latestRequest.newEndsOn;
+
+            setOldEndsOn(timestampMs);
+        } else if (isOpen) {
+            setOldEndsOn(new Date().getTime());
+        }
+    }, [isOpen, data, taskId, dev]);
+
     const handleOutsideClick = (e: React.MouseEvent) => {
         if (modalRef.current && !modalRef.current.contains(e.target as Node)) {
             onClose();
         }
     };
 
-    if (!isOpen) return null;
+    const handleOpenRequestForm = () => {
+        setIsRequestFormOpen(true);
+        onClose();
+    };
+
+    const handleCloseRequestForm = () => setIsRequestFormOpen(false);
+
+    if (!isOpen && !isRequestFormOpen) return null;
+
+    if (!isOpen && isRequestFormOpen) {
+        return (
+            <ExtensionRequestForm
+                isOpen={isRequestFormOpen}
+                onClose={handleCloseRequestForm}
+                taskId={taskId}
+                assignee={assignee}
+                oldEndsOn={oldEndsOn}
+            />
+        );
+    }
 
     if (isLoading) {
         return (
@@ -174,6 +213,7 @@ export function ExtensionStatusModal({
                         <button
                             className={styles.extensionRequestButton}
                             data-testid="request-extension-button"
+                            onClick={handleOpenRequestForm}
                         >
                             Request Extension
                         </button>
diff --git a/src/components/ExtensionRequest/Form.module.scss b/src/components/ExtensionRequest/Form.module.scss
new file mode 100644
index 000000000..7842fe610
--- /dev/null
+++ b/src/components/ExtensionRequest/Form.module.scss
@@ -0,0 +1,121 @@
+@import '../../styles/variables.scss';
+
+.modalOverlay {
+    position: fixed;
+    top: 0;
+    left: 0;
+    right: 0;
+    bottom: 0;
+    background-color: rgba($black, 0.7);
+    display: flex;
+    justify-content: center;
+    align-items: center;
+    z-index: 1000;
+}
+
+.modalContent {
+    background-color: $white;
+    padding: 2rem;
+    border-radius: 0.5rem;
+    box-shadow: 0 0 1rem rgba($black, 0.1);
+    width: 90%;
+    max-width: 28rem;
+}
+
+.heading {
+    color: $dark-grayish-red;
+    font-size: 2rem;
+    margin-top: 0;
+    margin-bottom: 1rem;
+}
+
+.formGroup {
+    margin-bottom: 1rem;
+}
+
+.label {
+    display: block;
+    font-weight: 500;
+    margin-bottom: 0.5rem;
+    color: $dark-grayish-red;
+}
+
+.textArea,
+.input {
+    width: 100%;
+    padding: 1rem;
+    border: 1px solid $light-gray;
+    border-radius: 0.25rem;
+    font-size: 1rem;
+    box-sizing: border-box;
+}
+
+.oldEta {
+    margin-bottom: 0.5rem;
+    font-weight: 500;
+}
+
+.dateTimeInput {
+    padding: 8px;
+}
+
+.formActions {
+    display: flex;
+    justify-content: space-between;
+    margin-top: 2rem;
+}
+
+.cancelBtn {
+    padding: 1rem 1rem;
+    font-size: 1rem;
+    border: none;
+    border-radius: 0.25rem;
+    cursor: pointer;
+    color: $white;
+    width: 48%;
+    background-color: $red;
+}
+
+.cancelBtn:hover {
+    background-color: $coral-red;
+}
+
+.submitBtn {
+    padding: 1rem 1rem;
+    font-size: 1rem;
+    border: none;
+    border-radius: 0.25rem;
+    cursor: pointer;
+    color: $white;
+    width: 48%;
+    background-color: $green;
+}
+
+.submitBtn:hover {
+    background-color: $light-green;
+}
+
+.errorText {
+    color: $red;
+    font-size: 1rem;
+    margin-top: 4px;
+}
+
+.disabledBtn {
+    background-color: $light-gray;
+    color: $dark-grayish-red;
+    cursor: not-allowed;
+
+    &:hover {
+        position: relative;
+
+        &:after {
+            position: absolute;
+            font-size: 1rem;
+            right: 0.5rem;
+            top: 50%;
+            transform: translateY(-50%);
+            opacity: 0.7;
+        }
+    }
+}
diff --git a/src/constants/constants.ts b/src/constants/constants.ts
index c295aa684..f2df2ca8a 100644
--- a/src/constants/constants.ts
+++ b/src/constants/constants.ts
@@ -6,6 +6,10 @@ export const DONE = 'DONE';
 export const AVAILABLE = 'AVAILABLE';
 export const UNASSIGNED = 'UNASSIGNED';
 export const PROGRESS_SUCCESSFUL = 'Progress Updated Successfully';
+export const EXTENSION_REQUEST_SUCCESS_MESSAGE =
+    'Extension request created successfully';
+export const EXTENSION_REQUEST_ERROR_MESSAGE =
+    'Failed to create extension request';
 export const TASK_STATUS_UPDATE_SUCCESS_MESSAGE =
     'Task status updated successfully';
 export const TASK_STATUS_UPDATE_ERROR_MESSAGE = 'Error updating task status';
diff --git a/src/interfaces/task.type.ts b/src/interfaces/task.type.ts
index b92a296be..f38bcd6fe 100644
--- a/src/interfaces/task.type.ts
+++ b/src/interfaces/task.type.ts
@@ -186,3 +186,18 @@ export type ExtensionRequestsResponse = {
     message: string;
     allExtensionRequests: ExtensionRequest[];
 };
+
+export type ExtensionRequestCreatePayload = {
+    assignee: string;
+    newEndsOn: number;
+    oldEndsOn: number;
+    reason: string;
+    status: string;
+    taskId: string;
+    title: string;
+};
+
+export type ExtensionRequestCreateResponse = {
+    message: string;
+    extensionRequest: ExtensionRequest;
+};