Create a 1 page form

Avg Bid (USD)
Project Budget (USD)
$30 - $250

Project Description:
Looking to make a 1 page form with 1 drop down menu + 4 columns of check boxes.
The form simply adds new values to the URL before submitting.

Check the attached image, this is how I want it to look.

The main question (the "what gift should i get") would be the category in the url:
The check boxes would act as tags:,column2value,column3value,column4value

I know how to do this, it can be done via simple HTML, but i want it cool looking with some error responses when a certain column is not filled.
The attached image is pretty much how i want it to look like, simple, with the same font... maybe a tad bigger but not much because this will be embedded in a overlay popup.
Extra space on top so I have room to play with (logos, adding a search bar ETC).

Instead of checkboxes maybe have the 4 columns highlight on click? IDK. I want something simple yet web 2.0. Can ya do it? If so, how much? :D

Skills required:
Additional Files: Concept.png
Hire DavidKosiba
Project posted by:
DavidKosiba United States
Public Clarification Board
Bids are hidden by the project creator. Log in as the employer to view bids or to bid on this project.
You will not be able to bid on this project if you are not qualified in one of the job categories. To see your qualifications click here.

$ 135
in 2 days
$ 55
in 2 days
$ 77
in 3 days
$ 35
in 1 days
$ 150
in 3 days
$ 75
in 2 days
$ 49
in 1 days
$ 150
in 2 days
$ 160
in 2 days
$ 100
in 3 days