Build a web form from an excel spreadsheet

Build a web form that performs like this excel spreadsheet, where the input at the top (highlighted cells) changes the return values of the form below. See attached. This web form will be placed on directly on the web page and it needs to store the data into the appointment form. The goal is to have the end user specify the values required, than that data is stored so that when that user books an appointment the data is stored with the appointment request. This is a sample page where this web form will be located: [login to view URL]