To get an idea what i need take a look at attached picture...
Besides this, there will also be inputs for:
note (needs no validation)
When user clicks SUBMIT, the data will be sent to server so that it can be emailed to me. Or he will be warned of minimum order amount.
Being able to lay the PHP part of my back too would be great...but if not, I will do it...
Example would be your best recommendation as this needs to be done today.