Opt-in box for wordpress

I am interested in having an opt-in box designed for my web page. My webpage is set up on wordpress so knowledge of WP would be required. I wish to have my opt-in box be a simple 2 field design, such as the pictures of the ones attached. opt in box to be 350 x 250 in size as this seems to be the size that fits my blog the best. I also would like my opt-in box to be 990099 for the box itself and the lettering of the title to be 000000. The header should read: "5 FREE Quick Start Videos to Grow Your Business NOW!" I wish for my button to be in FAFA05 and it to read: "Get My Videos" The lettering for this button should still be in 000000 This of course needs to work with my wordpress blog as well as my [login to view URL] autoresponders.