I do, I simply edit index.php to fit my needs. However, in wordpress 1.5 and everything there's a whole skinning system I'm not even trying to understand, that's why I keep on using wordpress 1.2
If you're good at this and want to offer the service, you might want to plug that in the Marketplace forums here (and get keyword specific ~ I've done searches on many forums to find just the right coder >> I look at their marketplace post as well as the nature of their posts overall to make a hiring decision).
That said, we're just using a default 'skin' - hardly any design to it at all.