A payment notice form

I'm a hosting provider and need a payment notice script. Here's what I want: 1). Informations will send to my E-mail box. 2). Three pages. 3). A simple neat template. First page includes: 1). Customer's name. (No need to separate First & last) 2). Contact E-Mail. 3). Choose a packge. (Drop down) 4). Telegraphic transfer or paypal. (Cheek box) 5). If chosed telegraphic enter your account's last 5 numbers. 6). If chosed paypal enter your paypal account. 7). Payment date, time and ammount. Cheek: ALL FORMS MUST BEE FILLED!! NEXT>> Second page includes: 1). Username your want. (Max 6 letters) 2). Password your want. (Re-enter) 3). Use my domain or plaese give me a free one. (Cheek box) 4). Enter the domain for your account. 5). Use our free domain. ([login to view URL]) Cheek: ALL FORMS MUST BEE FILLED!! SUBMINT>> List all the informations. Put a "Go back and edit to both pages" buton, Send. I need this script within 2 days.