Wordpress Landing Page

Dear Professional

We are looking to launch a new jobs platform but while we await completion, we are looking to start engaging our target audience through a landing page.

Also to launch our jobs platform, we are going to run a competition where our target audience can win a trip to one of 3 different locations of their choice.

What we need our target audience to be able to do is give us their First name
Last name
Email address

We then need them to select the type of job they are looking for from the following categories:
Job Sector
Job Location
Job Type
Job Salary

We then need them to select one of the 3 destinations they would like:
Destination 1
Destination 2
Destination 3

Then they click submit.

The next page would thank them for the information provided and give them the option to share on social networks
We would like to use a theme similar to http://www.elegantthemes.com/demo/?theme=Nimble
How much would this cost?
Cheers
H