FBML Contact Form - Facebook PSD to FBML XHTML

Hello, I've attached a screenshot of the Photoshop PSD file I've created for a contact form. I need this PSD turned into a FBML friendly contact form that will allow for multiple email addresses to receive an email. When the form is submitted, it should go to a "thank you" URL, which I will provide. Please look at this file before you bid on the project. I need this in under 24 hours if possible.