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Create "contact me" with drop down list and button

I would like to create a "contact me" portion inside my news column with a drop down list and a button (please see attachment). How do I do it in php fusion? Thank you.
The attachment option can't work for me, hence I am posting the picture below:

i6.photobucket.com/albums/y247/Fumiryu/Create%20contact%20info%20in%20php/Createcontactmeboxwithdropdownlista.jpg

Please help. Thank you.
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