Help with header for Wordpress Blog that includes aweber opt-in form

I'm in the process of shifting all my content to a main site. It's a work in process. I would love a header that includes my main free gift with an opt-in box....right at the top...So it's really two things...One to help me finish the branded header...and two for it to include the opt-in box.
How much would you charge?
Thanks.

 

opt-in has code for you place any where you want
Just open header file and paste into it.