Icon Form for Pretty Little Liars

<div style="background-color:#000000;padding:1px;text-align:center;color:FFFFFF;font-family:calibri;"><div style="letter-spacing:11px;font-size:20px;margin-top:10px;text-transform:uppercase;text-align:center;"><b>Requesting an icon</b></div>
<div style="font-size:9px;margin-left:10px;margin-top:10px;letter-spacing:1px;text-align:left;font-family:consolas;">
NAME [ ] NO NAME [ ]
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NAME: (optional)
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CELEB/ PICTURE:
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IDEAS:
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COLOURS/MOOD:
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ANYTHING ELSE:
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DESIGNER: @Fractured_Moonlight [ ] @monoatomic [ ] @Lol_That_Rhymes [ ]