Create a form and integrate with my co-registration program

This is some what simple task. Below is a screen shot of what kind of form I will need and it will need to be integrated to my co-registration program. The JavaScript code will be send to the employee. The fields on the form will not be the exact same. It will actually be less.

Want the exact replica. Not animated. Looking to get it done in the next 2-3 hours

Evner: HTML, Javascript, MySQL

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Om arbejdsgiveren:
( 7 bedømmelser ) Carteret, United States

Projekt ID: #4118935

Tildelt til:


****.. 12 YEARS of EXPERIENCE .. **** Hi. Ready to start; I can start right away. Thanks.

$40 USD in 0 dage
(76 bedømmelser)

5 freelancere byder i gennemsnit $72 på dette job


Hello, I can start right away. Please check your inbox for some questions I sent. Thanks.

$120 USD på 1 dag
(21 bedømmelser)

ready to start and finish next 2 hours for you

$40 USD in 0 dage
(21 bedømmelser)

We can get to work right now on this. I am online for a few hours now and shouldn't take too long at all. I have extensive JavaScript, PHP, HTML, CSS and many more language skills and you can view my portfolio for more Flere

$100 USD in 0 dage
(3 bedømmelser)

Dear Hiring Manager, I am a good PHP programmer and Designer, having experience of developing so many web applications in PHP, HTML5 and CSS3 with MVC joomla and wordpress.I know OOP with MVC architecture and yii f Flere

$60 USD på 1 dag
(0 bedømmelser)