add a form to this page

In Progress Posted Nov 11, 2009 Paid on delivery
In Progress Paid on delivery

Real quickie, I need a form added to the bottom right of the main image on this page:

[url removed, login to view]

The data from he form is then to be entered into a database.

I need the form to have the following:

1. Your name

2. Company name

3. email address

4. Contact phone

and a send button of course.

image attached on roughly where the form needs to go.

PHP

Project ID: #548441

About the project

19 proposals Remote project Active Nov 11, 2009

Awarded to:

LloydesignStudio

Hi lets start. thank you. Lloyd

$30 USD in 1 day
(160 Reviews)
6.3

19 freelancers are bidding on average $33 for this job

sristerweb

Let me start.

$35 USD in 0 days
(276 Reviews)
8.1
jexplorer

Please check pMB.. jexplorer

$30 USD in 0 days
(164 Reviews)
7.1
DesignSolutionSW

Please check PM.Thanks.

$30 USD in 0 days
(63 Reviews)
7.0
dagdya99

Lets start

$30 USD in 1 day
(162 Reviews)
6.8
techcity

Please view PMB for details. Thanks.

$45 USD in 1 day
(26 Reviews)
6.7
jsinfoway

Lets get it done.. Thnx JSI Team

$45 USD in 1 day
(72 Reviews)
6.6
inspirad

Hi, I am interested. Please select me as your service provider. Regards, Inspirad

$45 USD in 1 day
(68 Reviews)
6.2
barca2045

I can do it really quickly

$30 USD in 0 days
(52 Reviews)
5.5
kingyond

please check PMB.

$31 USD in 1 day
(9 Reviews)
5.3
offacc

Please check PM for details.

$30 USD in 1 day
(45 Reviews)
5.1
sat12345

Plz check PMB..

$30 USD in 1 day
(51 Reviews)
3.9
sas05

sir please check the PM.

$30 USD in 0 days
(10 Reviews)
3.3
rehaanron4u

Ready to start :)

$30 USD in 0 days
(19 Reviews)
3.2
cheapndbest

I am ready please check PMB,Thanks

$30 USD in 1 day
(3 Reviews)
2.2
BestForever

I can do it. please select my bid. thanks

$30 USD in 1 day
(2 Reviews)
1.9
progressiveway

Ready to start, please check PMB for more detalis.

$30 USD in 1 day
(1 Review)
1.4
indianexpert

ready to start...

$30 USD in 1 day
(0 Reviews)
0.0
uniquelogics

HI, I am ready to finish it in one hour. thanks

$30 USD in 1 day
(0 Reviews)
0.0