I am looking to get the attached image coded in html and css.
The form should be coded with standards, be semantically correct and use CSS3 conventions (will need to use vendor specific extensions).
Final design will be used on mobile devices.
Css can be embedded above the html
you only have to put 2 values in each dropdown. Just add another number or another value close to what is in the image.
Only have to put 2 states (does not matter which ones)
The upper right icon should also be done via css (no images)