Create HTML Form (CSS, DHTML)

Please visit this web page. <[login to view URL]> I would like to create the form on the left column. In addition the following improvments/features have to made... 1) Use a attractive and simple date selector 2) The current version has a collapsible feature if they want to add another coupon. I want this same feature. The improvment I want made is that if I clicked 'add another coupon' by mistake I would like a feature to undo the collapse. 3) Do not add the social media (twitter feature) 4) I would like javascript form validation 5) This will be part of a web page, so please create this as a widget which I can include in the main web page 6) Take into consideration that the main web app is in ASP. It would be great if you have a better & simple way to design this form. I am open to your suggestions. The style of the form should be similar to <[login to view URL]> Use the color scheme like this site <[login to view URL]> The style sheet should be such that I can in one central CSS file change colors, properties of any element within the form. The form should be easily skinnable. Requirements 1) Should be compatible with all major browsers. 2) Create 3 different variations of designs. I want it to look different.