Make my form look web 2.0 appealing w/captcha by webwired

I need someone to recreate my form to make it very visually appealing, web 2.0ish... I have attached a picture of what it currently looks like, then also a picture of something I tried with an online web form builder, but ultimately, did not work..... (Budget: $30-$250 USD, Jobs: AJAX, CSS, HTML5, Javascript, PHP)
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