Landing page required

I need a simple landing page built for my pay day loan site. The key information I need the page to capture are:
General Information:
Name
Address
Mobile
Landline
Email

Details of borrowing:
Mortgage Who, amount paid monthly, house value, mortgage outstanding.
Loans Who, amount paid monthly, Loan amount.
Credit cards, who, amount outstanding.
Other boorowings Who, amount outstanding

Protection details
Life insurance Y/N how much do you pay
Pension Y/N

The landing page should be able to be viewed by smartphones as well.

Any questions
Cheers
Mark