Bootstrap / Responsive / Form LAYOUT

Industry: Education
Kind of design: Landing page
Num. of web pages: 1
Description of every page: Please read this job very carefully. I post jobs to SAVE time. The winner bidder needs to make my life easier by following instructions and not asking questions that have already been answered.

The THEME we are using is here: http://themes.3rdwavemedia.com/college-green/v1.3/courses.html

You will create a PAGE that has a complex input FORM on it.

All we want is the LAYOUT -- nothing more -- no backend or server side technology whatsoever.

We do NOT want any javascript validation of the data either - we handle it server ourselves.

The starting field list is as per attached image. We want the addresses more elegant and the phone numbers to be a simpler list -- with the ability to add more (again do NOT do the logic only the LAYOUT -- e.g. make sure the design can handle additional phone elements without breaking down or "crumbling")

Do NOT worry about the contents of pick lists -- we will populate them.

Please ADD:

College / University
Employment
Experience (text area)

With field for number of years for each of the above items.
Ideas for the visual style: As per sample theme - just scoop out the left hand side (leave the right hand column in place please)
Things to avoid: Asking needless questions or involving me any more than absolutely required
Urls to draw inspiration from: http://themes.3rdwavemedia.com/college-green/v1.3/courses.html
Extra notes: Must look elegant and be in line with the theme

Must be hackable -- e.g. it doesn't break apart the moment we make a change.

Responsive -- it looks good on an iPad and a web browser