One Page Online Credit Application Needed for a Sales Website

I have a car dealership website. I just created a new subdomain which will serve as a one page credit application form. I'm currently in the process of getting an SSL certificate for that page, so that clients can securely submit a credit app directly to me. I need a designer or programmer to create the credit application for me. I have samples I can provide you, with all the necessary fields required. I don't know much about it, but it looks like some basic HTML is all thats needed. It'll be on a SSL SECURE page, however, so whatever works best. I have attached some samples for you to review. Again, its for ONE PAGE, WITH ONE FORM. NOT AN ENTIRE WEBSITE. Please bid competitively. I will have a local professional review the code and make sure it has no virus or malware or bugs.