Create Sign Up Form for ConstantContact email campaign for Wordpress site

Hello, I am looking for a developer who has built custom signup forms for Constant Contact before. My requirements are relatively easy but cna not be accomplished witht he simple plugin that constant contact provides. Here is what I need: We have 3 different lists in ConstantContact; 1. General 2. Sales 3. ISP We need a signup form that allows the user to signup for our mailing lists. EVERYONE will be signed up for the "General" list. We then need the user to choose if they want to signup for the "Sales" list or the "ISP" list. In the end, the 1 simple form will add their email to the "General" list AND either the "Sales" or "ISP" on the same form by utilizing a check box. The check box will default to "Sales". We will allow them to check both and in that case they will sign up for all 3 lists. The form will require they signup for either "Sales" or "ISP" or both. They can not leave that blank. The form needs to be able to be used in various different areas of our website. We will capture the following fields: Name Company Email In addition to creating the form, you will need to format the form to fit the design of our site and you will be required to add the form to 4 different spots on our wordpress site. We will give you temporary admin access to our WP as well as our ConstantContact account. We will test everything and it must look nice before we complete the project. 100% of the payment for this project will be made when the project is compeltely done to satisfaction based on the above requirements. We will only use Freelancer.com escrow and we will only work with developers/designers with high feedback rating. If you have questions about requirements, please ask me via Freelancer Chat. Thank you.