I need a Submission Form for submitsiteurl.com

General information for the website: Web Submission
Kind of development: Customization of existing website
Num. of web pages/modules: 2
Description of every page/module: This is a Web Submission Site www.submitsiteurl.com

I need a submission field please see attached. I will provide the html.

1. I need a website field and email field and submit button and progress bar.
1. I need the progress bar where it will be submitting to google, yahoo and bing if possible.
2. The progress bar will be about 8 seconds before it completes 100%.
3. When the bar reach 100% it will go to success.html (please see attached)

This project will be ongoing after this, dashboard and members area.
Description of requirements/features: Submission Form
Extra notes: Please make it professional.