Hey there! I took a look at the jpg, and I can handle this very quickly and efficiently for you. I'm an HTML/CSS master, and I believe in the web standards of 2013. All text will be selectable, and background images will be used where required. I can also get the form to expand to show additional fields as requested! I'd love a chance to work on this project. Please feel free to check out my profile and ratings. Let me know what you think, I'll be happy to get started tonight! I'll also happily upload it to the server for you so it will be live.
Thanks,
Nick