A pop-up form that will appear when specific new users access the website

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We are a south China-based news website launching a promotion with the Hilton Hotel in Guangzhou, China.
We need to design a pop-up with specific text, details of the offer, and a sign-up form. All users need to fill out the form in order to receive the offer. A check-box can also be provided if they also would like to receive our newsletter.
Here are the details:
Title: SCMP Readers: Enjoy a Special Offer from The Nanfang
Text: Enjoy 25% off the lunch or dinner buffet at OPEN (link: http://www.thenanfang.com/restaurants/guangzhou/yuexiu/open), a premier dining destination at DoubleTree by Hilton Guangzhou. Simply fill out the form below.
[First name] [Last name] [Email address] (check box: "Yes, I'd like to get the latest news from South China"
Privacy Policy (link: http://www.thenanfang.com/pages/privacy-policy)
The sign-up form will link to our MailChimp account. More details on that will be provided separately.
Please famliarize yourself with The Nanfang's style (www.thenanfang.com).
Thank you!
Industry/Entity Type
Hotel