Create online registration for an existing website

I am to move my product registration process from a physical registration card to online registration on an existing website. The website is already completed and I only require the addition of a page for registration. The registration page should contain the following queries: * First name * M.I. * Last name * Mailing Address * Home or Business * City * State * Zip * Home Phone * Business Phone * Fax * Email Address * Date of Purchase * Model Number (located on "Made in USA" sticker) * Name of Store Attached is a copy of the physical registration card that we are currently using.