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The code for the above is:

<form method=GET action="http://www.onelist.com/subscribe/ReWired">
<table BORDER=0 CELLSPACING=0 CELLPADDING=2 BGCOLOR="#FFFFCC" >
<tr>
<td ALIGN=CENTER COLSPAN="2"><i><font face="Arial,Helvetica">Subscribe
to ReWired</font></i></td>
</tr>
<tr>
<td><input type=text name="user" value="enter email address" size=20></td>
<td><input type=image border=0 alt="Click here to join ReWired"
                      name="Click here to join ReWired"
               src="rewired3.jpg"></td>
</tr>
<tr ALIGN=CENTER>
<td COLSPAN="2"><font face="Arial,Helvetica"><font size=-1>Click on the
image to submit</font></font></td>
</tr>
</table>
</form>

Just open the page you want it on in Notepad or a similar editor, and place the above in your page to add it.  You'll also have to download the small image used above and upload it to the same directory as your page...
Aaron