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 ([url removed, login to view] 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





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

Taidot: eCommerce, HTML, Ostoskärryt, verkkosivujen suunnittelu

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Tietoa työnantajasta:
( 54 arvostelua ) Tarpon Springs, United States

Projektin tunnus: #6801930

3 freelanceria on tarjonnut keskimäärin 271$ tähän työhön


A proposal has not yet been provided

$257 USD 10 päivässä
(39 arvostelua)

Hello sir, i am expert Web developer. i am really interested to do your work. i can done your work easily. Please discuss further details in message. Regards yillibrown

$400 USD 3 päivässä
(30 arvostelua)

Hi, here is my personal website and you can see some of project's here:[login to view URL] and if you like we can start discussing I want to improve my completion rate project to help you to reach the final decision. Lisää

$156 USD 3 päivässä
(7 arvostelua)

Our services includes all types of indoor & Out Door advertisement such as: Advertising (Print, Multimedia, Web,Screen & Thermal Printing) Event management Graphic design Photography Videography Product Ads St Lisää

$155 USD 3 päivässä
(0 arvostelua)