Custom Sign Up Web Page Form e-sign & Design Graphics

Please see attached picture. I am looking for someone to build a custom Sign Up Web Form & that knows how to design. I need a template to put on clients site so the coding has to be written and given to me with an example of it live (hosted on your site). As you see in the picture, I would like the following information: -First Name -Last Name -Email Address -Postal Code -Language of Choice Option -Check off box if user wants to receive emails from xyz company. -French Version of sign-up form. Mobile number field is already taken care of as it will be connected through an sms platform. I need someone who has experience in this and is a pro/expert. I need you to explain to me some things, where the information will go & how it is collected. iPhone Image: I would need an image of an iPhone similar to the one shown in the picture so that the sign-up form can go inside of. PLEASE SHOW ME PAST WORK when you message me. No down payment, I will pay in full after project completion. Thanks for your interest and hope to work with you soon!