571952 pre-registration page (one) 2

I need to create ONE page. It will be a registration page to get people to register to get on the waiting list for a new service. I will provide you with the layout for this page (PSD file). I will need to get the user email and few other fields. Then I will need give the options for connecting their account with some social networks so that we can count how many people they have in their network. We will give them points for everyone they connect with before they finish the registration. Register email name category (drop down box) connect with facebook twitter linkedin pinterest instagram