Lightbox contact form

I need a very basic lightbox form similar to this one: [login to view URL] orange gradient at the top instead of blue and half the height, orange gradient button I just want you to create the code to place on my webpages and I want a link that will bring up the form (I will place the code on my web pages myself) form will include: name - email - phone number - dropdown menu (and I will need to be able to change these values) form will send submitted information to email address If you need to clarify anything, please ask