signature form

<img src="http://i.imgur.com/5X3Fj98.png" width=400px">
<div style="background:f5f5f5;padding:5px;color:02bdff"><center><span style="font-size:40px"><b>SIGNATURE</b></span><br>
Title:<br>
Subtitle:<br>
Author:<br>
Images*:<br>
Celebrities:<br>
Subtitle:<br>
Ideas:<br>
Anything Else: