Landing Page

I need a custom landing page designed to compliment the design of http://www.guttergoyle.com. The landing page should follow the principals of the attached example while still retaining the basic look/feel of the existing site. The text should be easily editable in notepad with the heading done in html tags instead of a placed image. I don't care whether you hand me a php or html solution - just that I can edit the text to match the offer. The last 4 fields of the form are redundant and NOT necessary to the project. Please either provide samples of previous work OR a mock up of this specific project. I am going to make a rapid decision on this project as speed is critical. Thanks in advance -