555572 E-mail Signup Form

Hi, I have code from mail chimp for my e-mail newsletter signup form. I want you to customize it so that it will look like the attached image for my to be place on the signup page where visitors will use it to sign up. Please look at the attached image. I will then take the code you give me and place it on my site, which is still in development. If you can do this for me, please place a bid. :)