Copy one page of a site with one mod.

I need a copy of this web page http://www.fajmp.com/r/z/22888/CD21548/&dp=0&subid1= It can only be viewed from the us so please use a proxy if you have to. It should be a page with a cloth over a iPhone 5. The title is Presenting: The iPhone 5 The part I need to change is the question part. I need to put a email submit form where the questions are asked So insted of Question 1 of 3 Will you preorder the iPhone 5 Yes No I need it to say Enter in your email address to get your iPhone 5 then a button that says "Get My iPhone 5 Here!" I will provide the code for the email submit but you will need to clean it up to look seemless with the form. Deliverables should be well formated HTML and 1 PSD file for each page. I will need all files that were used to create the site. Including stock photos, font files, and psd files. All deliverable will be considered "work for hire" under U.S. Copyright law. Buyer will receive exclusive and complete ownership of all documents with complete copyrights to use and publish all work purchased as original content.