Convert image in to wordpress email form

I have a large website banner as a jpeg image (attached) As you can see it has a dummy email contact form, these need to be made to work to allow a user to enter details and submit. The forms are to send an email with the form details. The form must look as they do now so you will need to use CSS styling. The header image and email form will sit on a wordpress site so you will have the wordress functions to use. You must provide the code in a way that is easy to move from site to site. I don't mind copy and pasting code. The Form must have the following fields: Make - dropdown that takes makes of cars from a list in your code. Model - Textbox Your Name - textbox Your Number - textbox Finance - tickboxes Each field is required and you should have javascript validation for this Also the name of each field must be in the textbox until the user clicks it. You must demonstate that the form works on the standard Theme (twentyten). I have attached the banner. This is a simple project (no database or complex coding) and hence I only have a very small budget.