Custom form builder (Lakeland) - Outsource.com (Lakeland, FL) in Lakeland, Florida For Sale

I need a form modified from a Wordpress template.
Here's the page that comes with the theme:
I would need fields modified to meet client needs.
Please respond with hourly rate, estimated time on task, and estimated time to completion.
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Source: http://www.jobs2careers.com/click.php?id=xxxxxxxx89.96&job_loc=Lakeland%2CFL