Pop-In Builder

<form onsubmit="iPop_close()" target="_blank" method="POST"
  action="http://www.icoder.com/cgi-bin/arp3/arp3-formcapture.pl">
<table border="0" width="350" style="font:normal 10pt Trebuchet MS,Georgia,Verdana;">
<tbody>
  <tr><td colspan="2">
    <big>I</big>f and when we decide to launch this Pop-In generator
    <br>as a pay to use membership site would you be interested
	<br>in claiming an introductory offer discount?
  </td></tr>
  <tr><td>&nbsp;
  </td><td>
    <input type="checkbox" name="custom_discount" value="Yes" id="r1">
    <label for="r1">Yes!
    <small style="font-family:Arial;">I’m interested and would like
    <br>to claim my discount if and when you launch
	<br>this as a pay to use site.</small></label>
  </td></tr>
  <tr valign="bottom"><td><nobr>
    Your Name:</nobr></td><td><input name="first_name">
  </td></tr>
  <tr valign="top"><td><nobr>
    Primary email:</nobr></td><td><input name="email">
  </td></tr>
  <tr><td colspan="2" style="padding-top:1ex;"><center>
    <input type="submit" value="Count me in!"></center>
  </td></tr>
</tbody>
</table>
<input type="hidden" size="1" name="tracking_tag" value="popgenerator">
<input type="hidden" size="1" name="id" value="10">
</form>

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Pop-In Builder