Banner Request Form

<div style="background-image:url(http://i.imgur.com/FK6aCbv.png);repeat:no-repeat;background-color:#457177;text-align:center">
<div style="padding-top:150px;padding-left:55px; padding-right: 55px;padding-bottom:5px;">
<div style="line-height:15px;font-family: georgia;letter-spacing:1px; font-size:12px;color:#d6d2e3;text-transform:normal;text-align:center;">
<br> <b>Text You Would Like on the Banner: </b> [enter text here]
<br><b> Ideas: </b>  [enter text here]
<br> <b> Mood:</b> [enter text here]
<br> <b> Anything else: </b> [enter text here]