a draft for the "bad form page"

Hi all,
here is in attachment a draft for the form page and its list of features. I think I managed to make it really ugly and inaccessible -).
I'm still looking for a picture that could represent the "go" and "cancel" button.
Regards

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Tanguy Lohéac
Association BrailleNet
Tél.: +33 (0) 1 44 27 26 25
Web:
http://www.braillenet.org