Need script for my website!

What I need is similar to a shout box but I want it to have a little form area for name and US state to be entered and then submitted in real time to the “shot box type area”. I have seen these before, don’t know what they are called and have yet to find one. If anyone knows where I can get one or if someone can make me one that doesn’t cost a fortune please let me know price. Also it would be nice if the form area was editable.

Thanks Dirtdaddy

Perhaps you could supply your email for the freelancers like myself to email you?

Or contact me at freelance@tutelagesystems.com