Simple Single Page Website with jQuery Enquiry Process

We require a single webpage with a enquiry submission process.
What we're looking for is exactly the same as the example below:
http://www.citroenleasing.com/landing/index/id/37?gclid=C0azp-GNvrUCFaLHtAodqwsAMg

We can offer all hosting, domain name etc. We literally just need the page and jQuery script built.

We require this to be completed by the end of this week (22/02/12)

Any questions please don't hesitate to ask.