Need someone to make a word press with name, address, date of birth, 3 option for appointment time and attach it to a buttom

This project received 5 bids from talented freelancers with an average bid price of $40 USD.

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$30 - $50 USD
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Project Description

I would like someting like this but i would like to add 2 more options with date and time that a otaint would like their appointment . [url removed, login to view] this will be made for my website and the color will have to match
i will give u the website via private message

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