Buying Form creation

I need a "Request a Quote" form fill creating as follows:

5 input boxes; company, name, telephone number, drop down with 3 options, comments.

Also an image confirmation ... something simple with a small image containing a word, and an input box to check validation. The script will need to return a message of either:

Not all boxes have been completed, please recheck
Incorrect iamge validation
Thank you, we will contact you shortly.

The color scheme must match the website.
And the width of the form is limited to 230 pixels.

Please PM with an indicative price for this job and also confirm your experience.

Thanks

Gordano

 

Hi,
I can do this job.
Please check your pm.

Looking forward for your reply.


regards
anuradhan

 

hi,

I can deliver the best work in short duration.

Looking forward to your reply

Regards
Bruce Pitt

 

Hey,

I'll be happy to do this for $5.00

Let me know.

 

No more bids please. The job went to viral2583 - if anyone else needs a job doing I can recommend this DP member - very pleased with his work and support.