Create a short html page

Hello My name is Lloyd Burrell. I am the owner of [login to view URL] (which is a wordpress website). I would like you to create a simple html page on this website. Please note: * It needs to be exactly the same as the scan attached, same color and size font, same layout, same columns (one approx 2/3rds of the width of the screen and the other approx. 1/3 wide of the screen wide) - it should not have the wordpress layout of my website with the nav links across the top etc * I will supply all the text and the code for the webform (top right), and the images * You need to include the code for facebook box * All this information should sit in one screen (that's to say above the fold) so it needs making the right width to achieve this * When the page is complete I will need to be able to access it easily using cuteftp - I will need file name and location so I can access it * The links at the bottom needs to link to my existing pages (home, terms of service, privacy policy etc) If any of the above is not clear please ask. Thank you for your bid. Lloyd