Greetings! Sonicphobia Labs has very recently joined freelancer.com to focus on Drupal development.
I have looked over the attached JPEG and based on that, I would think, this job can be completed on the same day the contract is awarded.
You just need the HTML/CSS modified on your existing form to match the layout of the new one in the attached JPEG? You already have all of the code in place that the form calls, correct? If this is the case, please contact me and we can get started on this ASAP.
Thanks,
Levi @ Sonicphobia Labs