Online order form

Hello, I need to do a very simple web based mobile site (using jquery mobile or similar), I only need the front end to be done (html & javascript) + very basic design (jquery mobile template design is more than enough) the only added requirement is that drop down menus should be done using something like this scroller: [login to view URL] the purpose of the web mobile app is to submit alcohol orders, so the display would be as such: when the page is opened, the user would would get a page with 2 drop down menus next to each other, an input field for quantity, a " + " button below to add rows, and a submit to finalize and proceed to next page the page is divided as such: the first drop down menu would contain alcohol categories (for example: whiskey, vodka, etc.) next to this dropdown menu (or mobiscroller), there is another dropdown (dynamically populated based on the option of the first dropdown), in this dropdown, the user can select the item he wishes (for example, when vodka is selected from the 1st dropdown, the 2nd dropdown would show up things like smirnoff black, smirnoff red, etc.) next to this drop downs there is a box where the user can type in the quantity he wants for the item the display is almost exactly like this page: [login to view URL] (except that instead of days/month/year we have category/product/quantity), the top part will only be a blank space that shows the items added, there should be a " + " button somewhere to add the selection to the list a submit button on this page would take him to a 3rd page so the user can review his order and click submit to send out the order for the technical execution of dropdowns, let the data values be hard coded in the JS, i will implement them later to use AJAX, so please use JSON as data sources for the alcohol categories (whiskey, vodka, beer, etc), and the products (smirnoff, corona, johnny walker, etc)