Need Flash based application form create

Hi,

Can anyone re-create this html application form http://www.approvemysite.com/globalhair/application.html to be utilize in Flash MX 2004 (not Pro 2004)?

I need to be able to add a Merchant’s script to it when it’s completed. If that information helps.

Thx much!

a.ka. “Mocha Martha Stewart”