Need A Simple Contact Us Form..

[Jargit]

I made one with a tutorial. But when i went to add my own stuff, it messed up


====== = Text
====== = Password


thanks need these:

Desired Username-
Desired Password-
Confirm Password-
E-mail Address-

EzyRewards UserID-

(sub)Domain-
Type Of Site-


And make the button, so it e-mails me the stuff. Just leave space on code for my addy, ill add it after..


I cant really afford to pay, but i got a few old layouts i can give you with reseller rites... and ill rep u :D


thanks


PM OR POST CODE HERE PLZ :D