Browser plugin help - Javascript

This project received 9 bids from talented freelancers with an average bid price of $319 USD.

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We are looking for someone to help us create a bookmarklet, which we think is a browser plugin. Please see attached file. We'd like something similar to this. Specific fields will be given after the acceptance of project. But it's a simple form similar to this example.

The bookmarklet will also need to interact with our site and our database.

We appreciate the help!

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