Lead capture page

Im looking for someone to provide content, layout for a leadcapture page for \"myinternetbusiness.com\". The layout should be simple, white background, the top of the page \"rectangler box with my photo, and a headline, then content to grab the prospect- check out my mentor page at
www.100kincome4u.com and www.myinternetbusiness-mentor.com. Please dont copy. I need an opt in box, I have an aweber account.