Create a 1 page form

This project received 31 bids from talented freelancers with an average bid price of $73 USD.

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Project Budget
$30 - $250 USD
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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: [url removed, login to view]

The check boxes would act as tags: [url removed, login to view],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

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