Customize Mailchimp Form To Look Like Attached

Hi! STOPPPPPPP!!!!!! I will not look at your proposal if you copy and past your proposal. I don't need to see links to your websites and I don't need to see examples of works. YOU ALSO DO NOT SEE TO SEE MY SITE. ALL THE INFO YOU NEED IS IN THIS BRIEF AND ATTACHED. I WILL ONLY GIVE PEOPLE WHO FOLLOW THIS BRIEF THE WEBSITE LINK. I need someone to customize my current mail chimp form. The look of the current form is attached: version 1. I would like it to look like our app sumo form: version 2. I do not have the code and you will need to know how to see what form I have on my site is and create the form and replace the old form with it. Again, I don't know how to do this. Thus, I don't know if I need to use mail chimp or whether or not you can do this without it - nonetheless, it needs to link to mail chimp as the current form. Please do not apply if you do not know how to do this. You should know what you are doing and be able to finish quickly because you know what you are doing. Thanks! Alan