How to Re-Create the Edublogs Blog Signup Pages

Hi

I am trying to re-create the edublogs blog signup process.

I have anti-splog installed.

I want to make a nice signup form like the attached image.

http://edublogs.org/signup/?Pro=1

I want it to streamline the process of using Supporter (pro-sites).

Thanks for the help in advance,

Cheers

Johnny