Header form

<div style="margin:10px;background-image:url(http://i.imgur.com/kJHBAdB.jpg);color: white;font-family:Verdana;font-size:15px;letter-spacing:1px;padding: 10px 50px 10px 50px"><center><b>HEADER</b></center><div style="font-family:century gothic;font-size:11px;letter-spacing:1px;"><p>

<br>• Text :
<br>• Subtext* :
<br>• Ideas [be descriptive] :
<br>• Pix/celebs* :
<br>• Mood [mention colorful/dark/light/others] :
<br>• Password :
<br>• Anything else?* :
<br>• Will u give a free bump?* :
</div></div>