I need a jquery/php form for wordpress that pops up when someone tries to vote for an image. When it pops up, I want it to say "If you'd like your vote to count, please enter a valid email address, then a form to input email, and underneath that, a checkbox for "I would like to receive a promotional codes and discounts through email". Email needs to save in a database and has an export button inside of wordpress.
After they are done, there will be a "save vote" which will then close the window and save the vote.
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This can be real simple and does not need to be a full fledged plugin. I won't accept any bids over $100 for this project.