Shopify Form Template to be used in a landing page.

We have a finance form that we want to place on our website. Here is a sample application that one of our competitors is using:([login to view URL]) We want our form to look the same way and to have the same exact information to be submitted to us. We need you to provide the HTML or a .liquid file that we can use as a templates. Most important is we want the layout to be exactly the same as the sample form. I believe, a skilled professional will complete this job in two hours. If we are satisfied with the job, there will be more work opportunites later on! Please write if you have any questions or need additional information.