Single Web Page Added On Existing Site

I have an existing site at [login to view URL] and I need apage added on. I have a backend which allows me to add pages on anytime, but I can't do the code to accomplish what I want. I use 1shoppingcart with my site for everything, including the autoresponder and email list management. I will need a coder to make a page onto my site which collects visitor information and submits it to my 1shoppingcart email management area so the visitor and their info is added into my account, allowing me to follow up regularly with them. Here's an example of what needs to be done: [login to view URL] No need to create the graphics, header etc. However, I do want the featured property area as shown in the upper left portion of the page. I will provide a picture of the "featured property" and you will place it on the page with the description I provide...which will be short as seen on example site.