Changes to a PHP form

Hi , I have a PHP form [login to view URL] . You need to edit some elements of it. Please refer the images, then test the site and write 'I can do it in 2 hours max' in your bid. Milestones will be created and released after the work is done. You may download the site and upload in some place in your server to show me progress, then send me files after milestone creation. I have no problem but I don't have time. I WILL cancel the project and award someone else if you don't start immediately. I have 10$. Please don't bid if you need more.