mortgage lead capture landing page

This project received 6 bids from talented freelancers with an average bid price of $313 USD.

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Looking for a Landing page to be similar to [url removed, login to view]
my present website is built on wordpress, so if the site can be a page that i can stick in my wordpress theme that would be great, if not i could just have a separate domain name for the landing page.
the sample i supplied makes the client hit next to go to two additional pages, if it is easier i would not mind them hitting next, and then the remaining fields needed just get expanded on the same page. whatever is easiest.
page should allow me the ability to edit the bottom text (disclsoures) and possibly some Bullet points about my company on the side. once the client inputs the data on i would like an email with the info.

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