Wordpress HTML Email Form

Wordpress HTML Email Form

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Job Description

I need some one to build a simple email form that links to my mail chimp account and looks the way shown in the attached screen shot.

Here are the details:

A) The Wordpress install uses Standard Theme.
B) The HTML code will be inserted into the Header widget area
C) You will not have access to the FTP or the BLOG
D) You will simply generte the code and email it to me
E) I will paste it into the header widget and verify the work

What it needs to do:

1) Display the form, button and text show in the attached sreen shot
2) The form will be attached to the Mailchimp key of the desired list.
3) Upon pressing the button, the info will be sent to that list
4) Upon pressing the button the Thank You page of the connected Mailchimp list will be displayed
5) Look and display exactly as shown in the screen shot

I am VERY picky. I want it to look EXATLY like is shown in the screen shot. That means the font, color, sizing and all minute details must match exactly. If they do not you will work until you fix it.

If you do not understand the above instructions, do not waste my time or yours.

If you read all of this respond with 'rockstar' in the subject line of your bid.

I need this dont quickly and painlessly.

Screen shot: http://note.io/WMr7Ny (the red markings are for annotation)
Blog: 30x1.com