build capture 2 pages

I need two simple capture pages built. They will be similar for split testing purposes. All you need to do is create the page on test platform, and send me finished html files. I will upload to my server. I have attached example of what I need page to look like. Sales/optin copy will be different than the example. The example will use the same background image. I use getresponse for auto responder. Will like job to be finished asap.