FAST CASH $$ Need simple form

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#1

Please see: AmericanLifePolicy.Com

The form on the front page to transfer the information input to a partner site.

Here is the code I have:


/* Change Row Background Color When Moused over or clicked*/
function HighlightRow(ID, clsn) {
	if (document.getElementById(ID).className != 'clicked')
	 {
	 document.getElementById(ID).className = clsn;
	 }	
} 

function PopWin(URL,windowName, properties) 
{
  trainingWindow = window.open
  window.open(URL, windowName, properties);

}

function popwindow(URL,windowName, properties) 
{
	popupWin = window.open(URL, windowName, properties);
	window.top.name = 'opener';
}

function checkform()
{
	var err = "";
	if(Form1.state.value == "")
	{
		err += "Please select your State \n";
	}
	if(!Form1.genderF.checked && !Form1.genderM.checked) 
	{
		err += "Please select your Gender \n";
	}
	if(Form1.dobMM.value == "")
	{
		err += "Please select your DOB Month \n";
	}			
	if(Form1.dobDD.value == "")
	{
		err += "Please select your DOB Day \n";
	}
	if(Form1.dobYYYY.value == "")
	{
		err += "Please select your DOB Year \n";
	}
	if(Form1.coverageAmount.value == "")
	{
		err += "Please select a Coverage Length \n"
	}
	if(Form1.coverageTerm.value == "")
	{
		err += "Please select a Coverage Term \n"
	}
	if(!Form1.TobaccoN.checked && !Form1.TobaccoY.checked) 
	{
		err += "Please select your Tobacco Status \n";
	}

	
	if(err != "")
	{
		alert(err);
		return false;
	}
	else
	{
		//alert("Good");
		return true;
	}
}

Code (markup):

Please someone help me install this form on my site asap.