Minor changes on a submit form

Right now, the form looks like: [login to view URL] We would like: 1) The top part of the form to have "Personal Loans" and "Student Loan Debt" removed 2) The bottom of form, instead of the slider, have check boxes, starting at $5k-$9,999 and then $10k-$19,999 and so on up to $100k and then $100k+ like you see on [login to view URL] 3) When submitting from slider on home page to this form, the checkbox should be checked for most appropriate debt amount (e.g. if someone goes to page [login to view URL] , the $50k debt range would be automatically checked 4) Change title to "Finish Getting Your FREE Confidential Savings Estimate" Please confirm you can start today and finish today. Thank you!