Looking for email opt-in Facebook Promo Page / App ASAP

I am looking for a promo page similar to this: https://www.facebook.com/FitBodyBootCampGlasgow (refer to 'enter to win' tab, to view the page I mean).

I've finished my own design attached and will provide the PSD. The email details logged with integrated with the existing mailchimp account I have.

I appreciate there are free app builders on the market. I am looking for someone with experience in mailchimp integration and Facebook app building. I will need to see examples of your related work and know you can turn this around within a few hours. We will likely have 2 fields e.g. full name, email address then submit button.

UK person preferred. Deadline: 12 hours from start. Needs to be complete by 30th of December latest. Would prefer it was complete on the 28th December though.

High attention to detail required. Must be fast, productive and deliver results.

I look forward to hearing from you asap.