Autoresponder Pop-Up

We're looking for someone that can help us create an auto responder pop-up, just like the one found at the bottom of this page: http://www.rankmytattoos.com. The only difference from rankmytattoos pop-up is that we need you to add a drop-down menu listing 40 different tattoo designs of which the auto responder list will be segmented. We will provide you with the design in desired format. Once the prospect has signed up for the auto responder sequence the pop-up will disappear and it will not be shown to that particular user (IP) any longer. The code will be installed both on a WordPress blog & a PHP gallery page.