Customize Login Signup Box

Job Summary:

You need to create a customized login box setup for my Aweber autoresponder [Aweber sent me a solution in HTML code]. See below for more details.

Description of project:

You need to create a customized login box setup for my Aweber autoresponder [Aweber sent me a solution in HTML code].

It should have the following features:

1. The person (subscriber) must be able to choose in which language he wants correspondence from me, and on which language list he will be placed as a member.
2. The person (subscriber) must be able to choose his experience level in relation to a certain specified topic. There will just be 3 choices or experience levels, and just 2 topics.
3. It must be placed on the site, and it must work and look professional.

Skill requirements:

programming code