graphic design for optin ebook form

I need someone to create a well-designed and matching optin ebook form for this page: [login to view URL] It needs to go under the post(above the comments). it needs to match, and have the general workings of the attached images. If you read this start your bid with "graphic design ^o^" Winner will also have a simular job even easier and will recieve a bonus. Thanks ahead of time. - Josh