Clone of form with some modifications

I need a clone of the form attached in the zip file. See the attached file to see the following: 1. The link to the form we are looking to change is included 2. detailed description to for our requirements. 3. mock up of the additional change in the form we'd like to have. Please add on or 2 links to similar work if you've done. Please don't just say you reviewed our requirments and add a list of unrelated websites. I hate that and don't even consider folks who do that as it feels like the person hasn't even looked at our project. Thanks a million! Leslie ## Deliverables 1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. 2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables): a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment. b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request. 3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement). ## Platform Must work in all modern browsers, Firefox, ie6 and higher, google chrome, etc.