315696 Simple Joomla Landing Page

I need a Simple landing page done for a website I am building in the future. Please see the attached jpg. I have the design in high resolution to give to the successful bidder. 1. The template has to be 100% VALID CSS AND XHTML 2. The template must be 100% without any tables only divs. 4. the template needs to look perfect in FF, IE6 AND IE7 5. the template must include a module on the right hand side with functionality to take name, address, phone, mobile, email details saved to a database. dont mind what component is used to implement this whether chronoforms or other. This is a quick simple job for a joomla expert only reasonable bids will be considered.