More help, anyone good at forms?

Hey all, I'm looking for some more help with a new project I'm working on. I'm starting an online ad company and I need a bit of help getting the form page set up. It will need to have spots for customers to enter all the info relating to their ad. It will need to have a few pull down menus and have everything go to an email address.

I've got space on my other site I could set aside for it if you would need to upload any cgi to test it.

Anyone have any ideas?

I need it to fit into the following site design (no outdated buttons)

I'd be happy to return the favour with an ad or two. We specialize in custom ad sizes for pop-ups or to fit in specific spots. Here's a few samples of what we're doing:

(we're also back to college food if anyone's interested in hiring us for one - $9.99 for a fully custom job start to finish, or $2.99 for a plug-an-play.)

Sorry for the long post.

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