Sorry but it’s not ready.
There is a massive misconception that 404, email and coming soon files are easier to submit because they are smaller and less to them. In truth this is the complete opposite as it means that for a reviewer to judge premium value on a file with less components then there is zero room for error or issue.
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Your topography is not good and looks like the form is not styled in the same way as the rest of the page
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Uneven heights of the two boxes looks messy
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Spacing, margins and hierarchy all need work
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There’s a lack of attention to detail and with respect the design simply does not offer anything especially unique or clever