the wattpad form

<div style=background-color:f89719;width:200px;height:300px;margin-top:20px;margin-left:120px;>
<div style=font-family:arial;text-transform:uppercase;font-size:9px;margin-top:10px;margin-left:20px;>
<br><i> i'm requesting </i>
<br> <b> banner [] blend [] signature [] </b>
<br> fake [] real []
<br> text:
<br> subtitle:
<br> ideas
<br> actors/actresses/characters:
<br> anything else: