I think a very very simple UI is more appropriate here.
I also think we should add the actual email address to this page, @sam – I saw another site did that when I unsubscribed and I liked it, so you could confirm you were unsubscribing name@example.com and not some other person accidentally.
Remember, emails can be forwarded, and unsubscribe can happen from another person to your email – if the email address is shown there is a better chance of confirming the action, or skipping the action if it isn’t right.