415243 lead capture page

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I need a lead capture page.. I am using Godaddy hosting services.
here is the sample of the lead i needed design.
[url removed, login to view]

I have my replacement images.. the optin page will use feedblitz services. i have attached my logo and sample design image. I need the same exact font styles and look and feel.

My personal photo will be provided. ( its a png)I need a picture of success or items in the back ground of the main photo like the original website is showing ( see the guy). Please send your work samples.

I need this really quick. If done right, more work to follow. thanks

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