Need HELP creating a form

[micheldb]

Hi,

Is there someone that can help me create the following form:

http://www.rente-tarieven.nl/app/offerte.jsp

If you leave it blank and click send, just look what happens.
Can someone help me make this??

regards,

Michel

[DW]

At this time ListMail supports a form where the email address, first & last names, and up to 10 custom fields can be accepted.  The form you describe seems to have a few too many fields for LMP.  I recommend a simpler form, such as created by the ListMail signup-form generator (ListMail -> List Settings -> Signup Code) for accepting subscribers to your email list(s).

Regards