Create a Landing Page for my Website

I need a very simple landing page to acquire more customers. all the information they enter on the landing page will email me the inquire. I have a construction company and I need my customer to tell me what they need help with. phone number and email. Also, I will need help with Instagram and Facebook ad to target the l; landing page. attached is the exact landing page I want with the questions, I will use my own logo on top.