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Need a page/form created that outputs HTML

This project received 18 bids from talented freelancers with an average bid price of $148 USD.

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Skills Required
Project Budget
$30 - $250 USD
Total Bids
18
Project Description

I need to create a page similar to this one:

[url removed, login to view]


The difference will be that after submitting the data, it needs to be output in HTML so that I can copy and paste and use that data on classified websites such as craigslist

I need the output to look like a nice page with no URLs. I will be adding images manually so the image upload section will not be needed.

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