Replicating Landing Page Needed

We are looking for a programmer to create a replicating web page that will allow our users to simply enter their information to replicate the page. This will be a very basic replicated landing page. We would like several elements. The user should be able to customize a name field They should be able to enter in a form code for their own autoresponder capture form to appear on the page We need an optional field for them to add a embed code for a video. These are the main items needed. We are looking for someone who has experience with this and who can begin the project ASAP. Thank you