Started a 100 day design challenge today to improve my skills a little

The prompt for day #001 was the following:

Prompt: Sign Up

Create a sign up page, modal, form, or app screen related to signing up for something. It could be for a volunteer event, contest registration, a giveaway, or anything you can image.

Here's what I made today in 2 hours while banging my head against a wall.

Any criticism/recommendations are welcome