468856 Quote Form

I need a web/graphic designer who can design an insurance quote form. I have the code for the form, I just need a very good design to go in a place on my site and look nice with the colors of the site. The color of the site is black and grey, I will like this design in that colors. I have attached a sample design I did by myself to make the job easy and make the explanation straight forward. On the attached design, I have circled the form in red color. That's where I presently place the form on the site and you can check it out on the site. I want to move it to the top of the page. After you finished your design for the homepage, I should be able to copy your design and place it on other pages. You can design a sample and send it to me. That will help me to really know you can do the job. I need this job done within the next 4 to 8 hours. NOTE: I will prefer you ask me questions about what you don't understand about this job before you actually bid. Please, PM me if you have questions.