Blank's form

<div style="background-image:url('http://i.imgur.com/zeglhut.jpg?2');background-position:top right;background-repeat:no-repeat;padding:10px 0 20px 0">
<img src="http://images.cooltext.com/4359725.png" style="width:40px;height:100px;margin:10px 0 0 10px">
<div style="background: 78076C;width:300px;margin:-100px 0 0 70px;color:fff;font-size:9px;border:4px inset AD1C9F;text-align:justify;padding:10px">


<br>Title:
<br>Author:
<br>Subtitle:
<br>Summary:
<br>Picture links:
<br>Subtitles:
<br>Anything else:
<br>Password: