“Lead capture” landing page template for a PPC-SEM campaign?

Hi,

I’m looking to build a “lead capture” landing page which has a title, simple message and a form (e.g. Name, Email, Phone, Description, Submit button)

1) Is there a wp plugin that allows me to easily customize the landing page and form (e.g. add new fields) and store the leads in the wp database?
Other PPC features are also nice-to-have – such as “dynamically insert search keywords in the title/message of the landing page”, support multi-campaign management (change the landing page message depending on the campaign and keywords)

2) Is there a theme/template that already supports something like this – lead capture form? I didn’t notice one in the themes section.

thanks
Kiran