378851 Simple Lead Generation Page

I am needing a landing page built in a similar design to the image that I have attached. I am looking for something similiar, but that looks slightly different. I need the layout changed to a width of 700. change pictures, same colors. The form needs to be functional and post the data to another URL. The required fields are: Salutation First Name Last Name Address City State Zip Home Phone Work/Mobile Phone Email Address Confirm Email This is a pretty easy project, and details can be discussed over pm if necessary.