Coupon add to main page

I have a project that have to be like this: I want to add a coupon on my main page of my website !The coupon has to be very attractive to make people click on it!Once they click on it in order for them to print it (or to show up on their phone ) they have to add their information:last name ,first name,date of birth,home address,email address,phone number !Once they fill all they information than they can print that coupon that would clearly have all their information writen on it and I mean all the information!That information should also be made so that I can store it on an address book so that I can either mail them future coupons or email them future coupons!This list should be so easy to access that as soon as I have other coupons I should be able just with a click of a button to email to all of them without going to trash.......(maybe with an indication for them what to do in order for this not to end up in the trash) The coupon should be like I said very attractive with a photo (i will provide that photo )that tells a million words also it should give them enough information so that they have to print it in an impulse action !