Create a Mobile Website

I am an insurance agent and would to have a mobile site that can collect data and send the data to an email address. The site will likely only be 4 pages counting the main landing page. Each page will collect some information and have button to take person to next page until process is complete. Page 1: Include our Logo "Based on Louisiana Department of Insurance research some homeowners are paying 320% higher premiums on the same house and coverages. See if your company is charging you too much" "Please enter your current homeowner policy carrier" "BLANK FIELD" "Please enter current premium paid annually" $"BLANK FIELD" Page 2: "Comparative rating by Louisiana Department of Insurance indicates there are lower rates in your area" "Please fill out the following information" "Name: "BLANK FIELD" Date of Birth: "BLANK FIELD" Address: "BLANK FIELD" What material is your house made of (Brick, wood, metal): "BLANK FIELD" Year home was built: "BLANK FIELD" Year roof was last replaced: "BLANK Field" Amount of Coverage: $"Blank Field" How many claims have you had on the house? "BLANK FIELD" Page 3: Contact information Email: "BLANK FIELD" Phone: "BLANK FIELD" Page 4: Your new rate is being processed and you will be contacted on the next business day.