capture page for an affiliate

I am currentl affiliating get rich web sights i need a capture page making for my web site so when they go on my type my web sight or click on my advert they get taken to my capture page. they then type there email in it gets forwarded to my get responce account whilst they get taken through to the sight i am affiliating. so basically all im after is a capture page. for an idea of what i want it to look like go to [login to view URL]