170247 simple form - tonight

Hi I need a simple form integrating into this page - [login to view URL] All the text can be deleted apart from the title - Then the rest of the current text - "carsabout have a vast...." needs replaceing with the following - We use our extensive car valuations experience combined with Cap, Parkers car valuation and Glass guide valuations to give you an accurate valuation of your car. Getting your free Cash offer is easy, simply fill in the information below and we will then contact you by phone or email within 24 hrs - although usually much quicker. I would then like a form which will grab the information required - a link I can provide gives you an example of what we want.