Gravity Forms Customization

Closed - This job posting has been filled and work has been completed.
Fixed Price
Deliver by - February 9, 2013
10
Budget

Details

I am using a wordpress plugin called "Gravity Forms" and I want to replicate a form that was created in gravity forms for my website.  

I am attaching a image of the form that I want created in gravity forms.

If you are 100% confident you can easily and quickly do this job, then please bid.