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The layout is almost entirely a matter of styling, the .css part, as for the form, you have four text inputs, followed by four check boxes, followed by another text input, followed by a text area and a submit button. And since it's a flash file we have no idea what kind of action the form submits to, is it php, asp, or some kind of flash thing. And what can you use instead of what it is? PhP is very popular and well supported and would make a good choice.
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