Build a responsive landing page with fill-in forms that are emailed when completed

General information for the website: Landing page to gather contact information from potential customers
Kind of development: Customization of existing theme
Num. of web pages/modules: 1
Description of every page/module: This is just 1 page that has to be a responsive (as most traffic we generate is mobile).
It is a landing page were customers can leave us their contact details.

A preview has been generated in excel but needs to be converted to a webpage.
It can be visually pimped ofcourse if you have some good idea's :)
Description of requirements/features: Error messages when not all mandatory fields have been filled out: "Alle velden met een (*) moeten ingevuld worden"

Dropdown fields with a limited number of possible responses (see preview).

Sending the completed form in an email to stieven@insideblinds.com when people click the orange bar.
A message when it worked: "Veel plezier met onze inspiratie pack!"

Clickable links to our social media pages or other pages (see preview).
CMS and Admin requirements: None
Specific technologies required: None
Extra notes: