Customize Ticket

Customize Ticket
I have a JPEG of a ticket that I would like to have turned into a form with two fields. It just needs to be in the center of a web page with the ability for a site visitor to enter their company name and booth # and have it return a ticket that they can email or print.

See attachments for jpeg and PSD of ticket

This is for a one-time event and just needs to be very simple and basic.

Here is the artwork. Needs to be done Quickly.

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