Hi!
I am ready to start work on your project right now. I'll make the drowpdown given in attached demo, to inputs fields. But the functionality will not be changed. I am professional web designer and developer with 5+years of experience. I have excellent command on html5,css3,js,jquery,
bootstrap,php+mysql and ajax. I am very fast in turnaround and provide high quality work.
Please come on discussion for more details.
Thanks
Agile Soft!