28562 One page webpage with form

I need to work with a web designer to create my own lead capture page. 1 page. The content needs to be written, but I can give you a guide. Base it on: [login to view URL] Images need to be added too (graphic design). The form needs to do 2 things upon submition: 1) post the data to a external webpage which are in place (automatic subscription) 2) unsubscripe from our master mailing list I need your most competative bid. I have a small budget for this.