Create Sign up form with wordpress

I would like something like this created, near enough exactly how this is, but for solar industry, about saving energy [login to view URL] <-- Example Must be designed to work with mail chimp so i can get it set up with my sign up form. It needs to have the required fields; First Name* Last Name* Email* Phone Age * = Mandatory I won't overpay for this as i know its not a big job