Design of Popup and HTML conversion. See detail section.

I need design and HTML converted popup showing some hotel detail and ask users country and mobile number. I assume this box as two right and left sections. Following are fields required in right section----- Hotel Name Hotel City, Hotel Country Room Price Hotel Images - Images need to be some photo gallary which can show multiple images Fields required in Left Section---------- Message "Want to book this property ?" For Special Price Today. Call Us" 91 - 999999999 (Our Customer care number in bit big font) Or Fill following for and our Expert will call you Name (Text box) Select Country( drop down) Phone Number (Text box) Email (Text box) Submit button. Show label inside control as placeholder which goes away when clicked inside. Close popup button (x) Deliverables: a blank Webpage with a button/link. On click of that above detailed popup should open. PNG and HTML/CSS/Js/Images of popup.