I will pay for somebody to do this for me

I need someone to make me a form with text fields like the table in the pic at this address:

http://uk.geocities.com/mattdempsey@btinternet.com/form1.jpg

If this doesnt work, because sometimes it doesn't, go to

http://uk.geocities.com/mattdempsey@btinternet.com/ and click form1.jpg

I need this to be made in whatever format is needed, with the results sent to an email address in the format:

Driver : (what they entered)

etc.etc.

I need this quite urgently and if somebody can make it for me i will either pay or make a flash animation or website free of charge, as i am an expert in that area.

Please help, Matt

1) The Code Bank isn't for questions, it is for sample code only.

2) Read the private message I sent you about multiple posts of the same question.