Offline Form Simple $5.00

I am looking for an offline Registration Form with web 2 looks for people to manually enter their details. Easy and Simple NOW $10.00

First Name
Last Name
Username
email address
Gender : Male / Female
Date of Birth :
Street Address
Suburb
Region

Posting your design here will be great. Please leave some space for logo which will be sent once the design is approved.

Thank you all.....