see this page
[url removed, login to view]
has the code necessary to submit to salesforce....but the layout needs to be fixed up and things need to be removed. The source was [url removed, login to view]
See attached PNG of the changes. The basic thing is to remove the elements on the page so that the form is super simple to fill out.
The form should have what you see - name etc and to add one checkbox as shown (I agree to the terms of service) and the yellow box should be styled in such a way that its possible to add some descriptive text and expand and shrink the # of form elements without breaking the styling (yellow box should expand down as elements are added)