Enewsletter /add page to website

I have got ready sketch for the newsletter and need to have the final touch and add one more simple page to the existing website related with newsletter.

Page only have the information boxes need to be filled by potential clients

Page will have these information :
Store Name
Store Location
Contact Name
Telephone Number
Email address
Website
Please tick the box below representing your interest:
Book an appointment at our London showroom
Book an Area Manager to visit your store

To log in to website I will give you username ,ip address and password. You can log in easily by using filezila

Thanks