Creating a online Video squeeze page

Need to create a online software similar to this. [login to view URL] I have all the opt in template that you will need. so no design work from you I just need somebody to create a site that are similar to the link as above and the same style of usage. But i don't want it to be ZIP file, I will host the squeeze page for my customer. the end result for my requirement is a URL for customer. Conclusion, I need a site that customer can enter in the detail, aweber html code, video link embed and etc and then we will provide them with the site URL of the finished video squeeze page.