Build a form with on-line payment options

I need a form created for customers to type their information into on my website, and then pay for their ad insertion or annual print subscription. The website is www.moderneducation.co. The form will include: 1) First Name, Last Name (text field) 2) Address (text field, dropdown for state & countries) 3) phone number (text field) 4) email address (text field) 5) website address (text field) 6) Do you want to place an ad or subscribe to the print edition? (Pulldown) 7) For Ad: ad size (dropdown) a) Classified ad, 10 words, $10 b) 1/32 PAGE (2.4 x 1.4 inches) $25 c) 1/16 PAGE 2 columns (4.9 inches) x 1.4 inches $45 d) 1/8 PAGE 2 columns (4.9 inches) x 3.1 inches $80 e) 1/4 PAGE 2 columns (4.9 inches) x 6.3 inches $150 f) 1/2 PAGE HOR. 4 columns (10.1 inches) x 8.02 inches $275 g) 1/2 PAGE VERT. 2 columns (4.9 inches) x 12.9 inches $275 h) FULL PAGE 4 columns (10.1 inches) x 12.9 inches $500 i) FRONT PAGE AD 4 columns (10.1 inches) x 2 inches $315 j) Web only ad ([login to view URL] website & Facebook) $10 k) Other custom ad 8) Ad color pulldown (color or black & white) 9) Checkboxes: a. Create my ad for me ($15) b. I will provide ad 10) File upload button & field for ad, logo, or other images for the ad (allow multiple files) 11) Text field for custom instructions or text for Classified ad 12) Offer No. of months to run ad: l) 1 month m) 3 MONTHS (10% DISCOUNT) n) 6 MONTHS (15% DISCOUNT) o) 9 MONTHS (20% DISCOUNT) p) 12 MONTHS (25% DISCOUNT) 13) For Annual Print Subscription – Snail Mail ($15.00) 14) Add sales tax (7%) 15) No shipping 16) Offer several free options for payment a. Paypal b. Google checkout c. Amazon checkout d. Any other easy checkout option