Help With creating a form

I am using Boldgrid to create a website, and was wondering if it is possible to make a page set up in the following way:

I was wondering if there could be a form for people to fill out if they want to enter a page with a few required fields. Do you think you could set up the webpage like that? Where if they fill out the form and hit submit, they are taken to the page?

The page I need help with: [log in to see the link]