Amazon hosted single webpage. Background image. And, a form fill for email collection

I'm in need of a page similar to this one http://launchrock.com using Amazon hosting and a form fill to collect emails people will enter. The purpose is to collect as many email contacts and store them in a database while we get ready to launch the website.

This small project could lead to larger projects if we are pleased with your work. It will be a Brazilian website, but it isn't necessary to know Portuguese for this first project.

Project shouldn't take more than 2 hours.