Convert PDF Form to HTML/CSS

I have a PDF form used for timesheet submissions that I need to be converted to HTML/CSS

The form will have to be integrated into a Twitter Bootstrap theme that I will be using to build the application.

PDF Form: https://www.dropbox.com/s/9znvwmgdz4jkz3j/REVISED%20TIME%20SHEET%20071312.pdf?m

Bootstrap theme: http://wbpreview.com/previews/WB00U99JJ/index.html

NOTES:

-I will provide the theme files.
-Form does not need to be 100% visually exact. You can simplify things that might not be easy to reproduce in HTML/CSS (for example the diagonal column headers)
-Form does not need to be functional (I will do the PHP programming), only needs to look good and have all the needed inputs
-If you look at the theme I linked, you will see containers called "widgets". I will need the form to go into one of those widgets, but with "span12" as it's parent container, instead of "span6" so it will take full width.

If anything is unclear please post your questions in the bid.

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