This review has been awarded.
It doesn't look half bad. For you not being a designer, you did a great job. Your form box is good and I think thats where you should draw the rest from.
I should have been working on my client's stuff but I wanted a break and to do something else. lol So here is my version I threw together that was inspired by the form box and with all the same content. It's not perfect but I think it's a step in the right direction.