We need someone to get our Lead Capture Site fixed

We are a Real Estate Mortgage Lender in the US. We have developed a lead capture site that you can see at urnotaloan.net. It functions but currently does not send its content when done. It was originally set to send an email and do a XML push into our CRM. It also doesn’t scale well on smaller devices so we need the graphics updated and are looking for the ability to make copies on our website and on other websites easily. We are looking for the following: • Repair existing lead capture site so it sends its info by email and by XML push into our CRM. • Update graphics (can take off our parent corporate site at [login to view URL]) so it scales properly. • Set it up so we can edit the content. • Give us instructions so we can duplicate the script on another URL and tag it with a field that tells us what URL it came from.