I need a custom mail list signup form designed for Mail Chimp and deployed to my site

I need a custom mail list signup form designed for Mail Chimp deployed to my wordpress website. The signup form must look user friendly on both desktop and mobile.

NOTE - Mail Chimp requires Date fields to be entered as DD/MM/YY. I need format MM/YY so solution must be found - example - user form could include MM/YY and Mail Chimp Table could default to 01/MM/YY

Fields to be included
- First Name
- Email address
- Country - Ireland, UK
- County - List to be provided
- Are you or your partner currently pregnant?
If Yes - present option to enter MM/YY
If No - continue to next question
- How many children/grandchildren do you currently have?
Allow user to select a number. If greater than 1, allow user to enter multiple MM/YY birth dates
If zero, continue to next question
- What brand of nappies do you use? (list to be provided)

Website is www.babydocclub.ie

Please quote BABYMAIL to show you have read the brief.