Custom Optin Form

Hello, I have a simple task that I needed done. I would like to add custom optin form underneath one of my videos. The example is attached, please see. Visitors would simply be able to choose a payment option and depending on which option they choose it would redirect them to the order link after they enter their email and click 'continue to next step'. Using the screenshot I attached of the example let me list out some specifics. 1. On the left side of the form the only thing you would change is 60 day money back guarantee to "30" 2. On the right side of the form mine will say * Full and Instant access to Membership Marketer Mastery Training with all lifetime updates. * Bonus of Free Website Critique (valued at $997) * Bonus of Free 30 Minute Phone Consultation ($1997) Total: $3,000 Value Yours For Just Three Payments Of $97 3. After you have completed the form I should be able to take the html code you provide for me and insert it into my video code that allows for this to show up at the time I specify. [login to view URL] If awarded projects I will give you further information that you'll need to complete (ie. autoresponder login, order form links)