46830 Name Capture Page Design

This is a simple project for the right designer. I want a very experienced designer with a good portfolio of similar types of pages. If you have any negative feedback don't bother. Also don't bother bidding if you are new and have no feedback - sorry I don't have time for roulette here. If you work fast and deliver quality work I have plenty more for you. I need a nice design for a lead capture page which will be an opt-in form with fields for the basics such as name and email address with an additional element for the answer to a question with radio buttons. I also need the 'subscribe' button on the lead capture page to open a popup window that tells people that they must check their email and confirm before they will get the report which they are requesting. This project is for design only and formatting but not writing - I need a bulleted list with design elements but text will be added by me later. I will provide an example of a page that I like if I choose you for the project. I also have a few images that I will give to the designer once chosen but some additional graphical work will be necessary for design elements etc. All work will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased.