WIDGET design

So I need a widget made to fit on my web site (300 x 300) that harvests data. (see image example) I need that data emailed to me when the user fills out the form Data must be HTTPS secure * see example of working widget here at [login to view URL] You can see at right side of page, middle ====================== WIDGET DATA NEEDED TO BE HARVESTED ====================== -------------------- BORROWER INFORMATION -------------------- First Name: Last Name: Amount of loan requested: State: Email: Phone: Skype: ----------------------- CO-BORROWER INFORMATION ----------------------- First Name: Last Name: Email: Phone: Skype: -------------------- PROPERTY INFORMATION -------------------- Property type: (single family resident/condo/manufactured/multi unit) Occupancy: (owner occupied/rental property/second home) Loan type: (new home purchase/refinance/cash out) ----------------- If Purchase ----------------- Is this a purchase pre approval: (yes/no) What is the purchase price: Do you have a purchase contract: (yes/no) ------------------ If Refinance ------------------ What is estimated value: How much is current balance on 1st mortgage: How much is balance in 2nd mortgage if any: How much cash are you needing to pull out: ----------------- INCOME AND CREDIT ----------------- Gross monthly household income: Do you currently own s home: (yes/no) Ever have a bankruptcy or foreclosure in last 3 years: (yes/no) How much cash/liquid assets do you have: How do you rate your credit: (poor/good/great/excellent) Do you know your credit score? If so, what is your score: Employment: (Self, Salary, Commission, Retired, Social security/disability, Pension, Military)