tRYING TO MAKE A REQUEST A QUOTE

I NEED TO MAKE SOMETHING LIKE THIS RE-DOING THIS WEBSITE AND I CANT FIGURE OUT HOW TO REMAKE THIS WITH XARA


http://meetah.ca/quotes/

Amy help would be grand. thx.

I think a lot of people here embed Jotforms... I use machform...

Thank-you I will look in to that.