Build a Website Squeeze / landing page (Project LinuxFreak1985)

Please find and an example of the autoresponder I am looking for here http://www.phpautoresponder.com. There are many free ones. If you could I would like the pages to have 1.) The same color schemes as the sample mock pages I have attached 2.) *Must* State on the page that. (The customer is entering their information for "A free consultation" and "A free initial Credit Consulting") having this bold somewhere written in RED would be nice. 3.) I would love to have some type of free PHP script autoresponder to do a drip email campaign. 4.) You must host the page The customer "submit form" should have: 1.) First Name (Mandatory) 2.) Phone number (Mandatory) 3.) email (Mandatory) 4.) Credit Problem field (with drop-down menu with) 1.) Want to buy a car. 2.) Want by a house 3.) Want a Credit Card. 4.) Student Loans. 5.) In foreclosure