Develop page (UI) for existing web site

The existing web site needs extra page to be created. I do not need HTML or new design for web site. You create UI for new page (PSD) with based on current web site's design. It is more UI work than a design. The new page will includes: couple of textual blocks with titles, web form with text area and submit button, table with list of information. Check this wire frame: The project is VERY simple. I am ready to pay 25 USD for it, +25 USD as bonus if you make it nice and fast. There are two main requirements: [login to view URL] 1) No milestone payment unless you show me some progress (no project give up). 2) If you do not reply within 24 hours I cancel project and you get no payment.