Need One Page Built

I've attached an image to show the page I want built. I would like First Name, Last Name, and Email Address to be required when they hit the submit button. If they are not input, then they should be prompted to do so when clicking submit. For now, have the "Submit" button direct to google.com after the form is submitted. This form should be sent to my email address everytime it's submitted. I'd like someone who is available to do this right now. Thanks.