Exit Page design

Design one web page. The page is the Exit page. When the viewer clicks the close button or navigates away from the site the exit page will come up. I have the software to do this so I do not need this done. I need the exit page designed. The page is to contain Bullet points, be very easy to read, grap their attention. Contain a 3D DVD cover and disk. An area for them to submit their Email and name so they can watch the free dvd, once they submit this they then get a email containing a link to watch the DVD bonus. I can show you another site which has what I mean. Small job, should not take long for experienced designer.