need help with mini-website and hosting?

Closed - This job posting has been filled and work has been completed.

Job Description

I want to create a mini-lead-capture page.

Look:
http://screencast.com/t/W0qXYlDo

this is what I would like to model.

How would we create a website like this?

With a shiny button like that?

And the three different steps?

Where would this be hosted?

Would be great to get it within 3 days.

Thanks a lot, Mark Tetzner