Beta Tester Landing Page

Hello, I'm wondering if it would be possible for you to build a page for me. The basics are, it will be a landing page where we will collect basic demographics on potential beta testers for a new service/software we are developing. I needn't be too complicated. The logo at the top. The copy as written by myself then fillable boxes to collect First/Last Name, Profession, Employer, Operating System, Country of Origin. They will then need to be able to read and "click" acceptance of a Beta Testers Agreement. Then "send." I would like for all of this collect information to be inputted into a database via SQL. I can give you a clear example of something that if very similar to what we want. Please view this page: [login to view URL] As I said, I will not need any of the links and things at the top. This is essentially only to collect the fields and put them into a data base for us to chose from later. If this sounds like something you can do, please let me know ASAP as we're hoping to have this done immediately... Warmest Regards, Greg Beaty