Design a popup to promote products & collect visitors information

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Hire me! I am a Server Admin / PHP / Mobile APP Developer, you can trust. I am Olaitan Mayowa. Full time Professional Remote Server Admin / PHP / Mobile APP Developer. I have many years of experience in PHP/MySQL/Server Administration.I have strong knowledge in all web technologies. I specialize in PHP, MySQL, WordPress, Laravel from full website setup to minor tweaks/bug fixing. Also expert in HTML, CSS, JAVASCRIPT, JQUERY & AJAX and also mobile developer . I also maintain, update and set up servers. I offer services that are geared towards small and medium sized businesses ranging from file servers, backup servers, active directory servers for file security and authentication and web based servers for Internet such as web servers. I have worked for individuals as well as for big concerns. Contact me if you value your money and need quality remote PHP developer/Server Admin. I Maintain a steady stream of clients & provide the best solutions/support is my additional strength. I design awesome websites for our clients to help meet their online target and goals. I also deploy latest technologies in making sure my clients get the best online presence they require. Please initiate a chat in freelancer.com and feel free to discuss your requirements. As soon as you award the project, I will be available for you in Skype/Gtalk/Yahoo Messenger/Gmail. Thank you for spending your valuable time on my profile.I am looking forward to contribute to your success. You dream it. I build

I have experience in dealing with this problem What should be in the form? Do you need to drop-down lists or radio buttons?