Create an HTML form

I need an HTML form created based on a hard copy form. You don't have to worry about what happens when it is submitted. just take the MS Word document that I've attached to this bid request and create a form with all the fields indicated. use meaningful names for all the fields for example (patient_street_name, patient_city, patient_zip_code) the table it lives in must be no wider than 474px wide, but as tall as you like. don't add any fonts or style sheets or any other kind of formatting. Here is an example of the last one I did. Its a good reference for you: [login to view URL] ## Deliverables 1) Complete and fully-functional working program(s) in executable form as well as complete source code of all work done. 2) Deliverables must be in ready-to-run condition, as follows (depending on the nature of the deliverables): a) For web sites or other server-side deliverables intended to only ever exist in one place in the Buyer's environment--Deliverables must be installed by the Seller in ready-to-run condition in the Buyer's environment. b) For all others including desktop software or software the buyer intends to distribute: A software installation package that will install the software in ready-to-run condition on the platform(s) specified in this bid request. 3) All deliverables will be considered "work made for hire" under U.S. Copyright law. Buyer will receive exclusive and complete copyrights to all work purchased. (No GPL, GNU, 3rd party components, etc. unless all copyright ramifications are explained AND AGREED TO by the buyer on the site per the coder's Seller Legal Agreement). ## Platform 1 properly formatting HTML file [login to view URL]