Create A Web Page From A PSD Photoshop Image

I have a web page design from [login to view URL] that was created as a PSD file (photoshop). It has one simple opt-in box with 2 input boxes (first name,last name) and a submit button. What I need is simply nothing more than to take this lifesize page image, and put HTML to it where the form is live. So, the only thing that needs be done is this image converted to a webpage, and the two spaces for the input boxes and the submit button to be a functional form. This is a -=RUSH JOB=- and NEEDS to be done as soon as possible! Will be checking back on bids every 5 minutes, first decent bidder wins. Will give you both a PNG image file and a PSD image file to create the HTML version of the page from upon chosing the coder. Thanks! Remember, it's a RUSH job, so get your bids in quick to make a quick buck! -Kevin