Build a simple web form that inserts data into a SalesForce data extension

I need a talented web developer who is specifically skilled in SalesForce Marketing Cloud to create a simple web form that inserts data into a SalesForce Data Extension File. The web form should include the following fields: - Select your Business Development Manager (drop down menu with the names: Matthew Mickal, Kandy Magnotti, Kyle Christensen, Kathy Donnelly, Joanie Field, Grace Ambrosia, Drew Santiago, Melanie Santos, Stephanie Bujak, Thomas Panici, Yaritza Maldonado, Aisha Carver, Katy Rose, Lisa Mcclellan) - First Name - Last Name - Email - Travel Agency Name - Country (drop down menu with the countries: US United States, CA Canada, PR Puerto Rico, Other) - Address - City - State/Province (drop down menu with the states/provinces: AL Alabama, AK Alaska, AB Alberta, AZ Arizona, AR Arkansas, BC British Columbia, CA California, CO Colorado, CT Connecticut, DE Delaware, DC District of Columbia, FL Florida, GA Georgia, HI Hawaii, ID Idaho, IL Illinois, IN Indiana, IA Iowa, KS Kansas, KY Kentucky, LA Louisiana, ME Maine, MB Manitoba, MD Maryland, MA Massachusetts, MI Michigan, MN Minnesota, MS Mississippi, MO Missouri, MT Montana, NE Nebraska, NV Nevada, NB New Brunswick, NH New Hampshire, NJ New Jersey, NM New Mexico, NY New York, NF Newfoundland, NC North Carolina, ND North Dakota, NT Northwest Territories, NS Nova Scotia, NU Nunavut, OH Ohio, OK Oklahoma, ON Ontario, OR Oregon, PA Pennsylvania, PE Prince Edward Island, PR Puerto Rico, QC Quebec, RI Rhode Island, SK Saskatchewan, SC South Carolina, SD South Dakota, TN Tennessee, TX Texas, UT Utah, VT Vermont, VA Virginia, WA Washington, WV West Virginia, WI Wisconsin, WY Wyoming, YT Yukon ) - Zip - Phone I have already created the Data Extension in SalesForce with the above fields. I just need a landing page created with a web form that inserts the above data into the Data Extension. Very simple, clean and functional. I can also provide an image and short copy to use on the landing page as well. But the web form is what I need help with. I tried doing it myself, but I was having trouble with the form side padding. I have attached what the page should look like on the screenshot titled (BDM Newsletter Sign Up). Also, I attached a screenshot titled (DE-BDM-Newsletter-Sign-Up) of what the Data Extension Name and Fields that I created look like in SalesForce. And, I have also attached my code that I tried to adjust but kept getting errors, it should just be a simple one page process. I can provide and answer any questions you may have.