Java Popup (exit popup) required

I require an Java Exit POP up to be made for my website, which gets in the Users screen as they Exit my webpage. I have provided a picture (attached) of what the design should be like. This task requires HTML, code editing, and the final output needs to be in Javascript ! It is an Email Autoresponder Opt in, which collects the persons email address + their name. This job should be EASY for somebody who knows what they are doing. I am using the Autoresponder service, Aweber. I have done a rough Design/picture for what is required, PLEASE VIEW ATTACHED FILE. As I am using the Autoresponder service =Aweber, I will provide you with the HTML for the Opt in box of the Email submission and Name submission, and you can take code and do the design from my picture, and work from that. The pop up must open in a new box, and should be a Small box, (size in my included attached file) Like i said , this job should be EASY for somebody who knows what they are doing- Bidding Price for this project is about $5 - $10. Please State your bid, and ask me any questions !