Design a Form

Hi, I would like a Form to be designed for my website socialmediapool.com. The Form needs to be similar to [login to view URL] There needs to be additional validation. The Pricing appearing in the drop down should be taken from my website [login to view URL] Whenever a Drop down is selected the corresponding Text Area should be made mandatory. When the user clicks in the Text Area, The text area should clear. If the user fills something in that text area it should remain. Else the text whichever was present should be displayed back. Please let me know if you have any Questions. Thanks, Vijay