askslicky.com

i need some to make me a form which would include a brief discription box, email box,name box and location [login to view URL] a clear and submit button on the bottom of the [login to view URL] after submitting all information will be sent to my [login to view URL] note the form will not all the user to submit until all boxed are fill out and the email must be [login to view URL] a Word Verification will be needed before submitting the information.