Create a basic web script

Hi I would like a basic web form created. on the index page of our website we have an example script of 3 fields. The user will need to type in there username, email address then select between a drop down of 2 packages, basic or advanced. If they choose basic, they go to another page that will show the 3 fields they have selected, such as username, email and the package they choose using the design of our website. That is stage 1 complete then they move to stage 2.. They then need to enter there address and postcode and confirm there email address, then they move to stage 3, they then enter a moto which is 60 words of there choice then they enter the kimo moto2. They then need to digitally sign by entering the first and seconds name. once done they go to stage 4, they then should see a price of £1.00 and paypal buynow button all done nice and neat within the theme of our website. They then MUST purchase this for £1.00 and once done sent back to the form to click complete. Once they click complete they get a message saying thanks for your payment your form has been sent successfully. The info what they typed should be generated onto a blank .jpg image form that I have attached. We are then sent this form to our email address.... I will make a new project for the advanced section which is actually just the same as this but 8 extra fields... Please only bid if your english is good and you can do this today. our website is [login to view URL] when you press the green button that will be page 2 and you will see the design we are after. The current form is just an example. and the final image that the info needs to be inserted in to and sent to our email is, I will adjust the form at the end but this is a example to work off..