Very Simple Template Coder Needed

Can someone do this quick template for me including the text box at the bottom and the selector if possible :)
I know it doesn't seem like much but it really is.

http://img50.imageshack.us/img50/724...emplatecn4.png

Thanks.

:bump:

Edited by Agesilaus (Forum Moderator): Please do not multiple post to bump threads without adding new information.