character card/banner 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;line-height:35px"><b>CHARACTER GRAPHIC</b></span><br>
Card [] banner [] <br>
Character name: <br>
Title:<br>
Author:<br>
Summary:<br>
Ideas:<br>
Pictures: <br>
Color Palette:<br>
Text to be included: <br>
Font Ideas/Mood/Theme:<br>
Anything Else: