HTML + PHP Project

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Please, see the PDF attached.

I have a html code and I need it displayed without unformatting.I have 2 fields (they are table cells) I need to be displayed without unformatting of the page.

The project consist:
- Fix the code between to not distort the page - they are textfields.
- Both text on fields are used to the email will be sent by a php code.
- Fix the [url removed, login to view] to load another page after send the email.

No javascript and css allowed.

All code will be sent.

I need ASAP - I need the code in the next 2 hours

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