URGENT - Simple Delphi Application - (repost)

This is a simple job for a good Delphi coder who knows what they are doing... I urgently need a version of the attached application All i want to do is change the name and alter the layout so its slightly diffrerent so I dont get issues from the inital provider. I do not own the software or have any source code so would need coder to create it from the start.