Create Very Simple One HTML Page for Online Poll URGENT

I need a single html page created. The objective of the page is to take a poll. The visitor will click next to the selection and enter submit. Afterwards they should receive a Thank You message. I want the page to be very simple so it will load very quickly and easily. I want their selection to be saved in a file along with their IP address and any other data you can capture through the browser. I am attaching an example of the page. I am looking to hire someone right away.