Create a order form

I am looking for a freelancer who can program the following order form for a "one-product-website": All information shall be saved inside a database: - Each order shall get an order number - Some textboxes - Voucher-textbox: Depending on the voucher code, the price shall be either reduced or set to zero. The shall be some settings possible whether a voucher can be used several. If not, the user shall get a message if code is already used. There shall be a function to import new voucher codes. - Textarea (number of lines AND letters shall be limited) - 2 Checkboxes (I accept the terms of use and other one) - Dropdown to select way of payment (Bank transfer or paypal) IF paypal is chosen: Connect to the paypal account and make immediate payment possible. The information that the article is paid, shall be then saved in the database Depending on the way of payment, two different mail texts shall be send to the customer. IF Bank transfer is chosen: There shall be a bulk function to important the order numbers paid via bank transfer. The information shall be than saved in the same field of database (see Paypal Payment) As the order form shall be integrated via Iframe to current website, I am looking for a white background, but with graphically appealing order form.