Design a simple 'astrological' landing page which will capture key customer details

We need a very simple landing page which will be attached to an Opencart website. The background can be an image of stars / galaxies / whatever you think appropriate.

The title is: The Astrology of You

Then we need a little sales copy:

"The Very Best Astrology Report on the Web!
Experience the most complete, detailed and comprehensive birth chart interpretation. This is not just another quick Sun sign horoscope, but a full 25+ page Natal Report - a true birthday horoscope giving your blueprint for life based on the date, time and place of your birth. Unlike other instant services available on the internet, our experienced astrologer personally goes through each chart adding comments, helpful advice and discusses how to tackle specific areas of challenge.

Your Natal Chart includes:

* Often overlooked but fundamental information on Elements and Modes - which have profound impact on your personality and how you deal with life
* Thorough examination of your persona, how other people see you, true vocation and status, aptitudes and strengths, emotional needs and responses, mentality, attraction and sexual drive, faith and where you will face challenges in life
* Key advice on the best and easiest way to tackle the challenges in your life highlighted in your natal chart
* Smartly presented in a concisely written and easily read report around 25 pages in length

Simply enter your details below."

We need visitors to enter their details into boxes for:

Name (First and second), Birthday (drop down list of Day / Month / Year), Time (drop down list of Hour / Minute (Universal Time only), Birth town (drop down list) and Country of Birth (drop down list)

We also need them to enter their email address and finally we need a box where customers can enter a voucher code for discount.


It is important that the voucher code box links up with the Opencart Sales/Coupon system behind it. All the other data captured can either go into the Opencart system or into a form where it is easily used / cut and pasted etc.