Need a form for my site

Need a form for my site

I need a form that is similar to this:http://www.40billion.com/tweet

The form must collect the users:
- Tweet (120 characters max)
- A URL of their campaign
- An image to be used in the tweet, shorten URL with owl
- The time of day they would like their tweet tweeted out
- The plan that they select ie: copper, silver, gold, platinum
- customer email
- need it to be compatible with PayPal

If possible but not necessary:
Next what I need is above and beyond these tasks is I need the data collected from the above form to go into an automatic scheduler to be tweeted at the requested time that the customer selected, I understand this may be a tall order but if it s do-able I would like this done

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Requirements

The form must collect the users:
- Tweet (120 characters max)
- A URL
- An image to be used in the tweet
- The time of day they would like their tweet tweeted out
- The plan that they select ie: copper, silver, gold, platinum
- customer email
- need it to be compatible with PayPal

If possible but not necessary:
Next what I need is above and beyond these tasks is I need the data collected from the above form to go into an automatic scheduler to be tweeted at the requested time that the customer selected, I understand this may be a tall order but if it s do-able I would like this done

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Skills Required

Coding Programming