Order Page

I need the necessary fields for placing an order at my website. My order page has six small photos down the left side and six small photos down the right side. Between the photos is text explaining each item for sale. Note: larger photos of the items are displayed elsewhere at the website. What I need are the fields for the customer to type in his/her name, email address, radio buttons to select a credit card or Paypal, 12 check boxes for selecting which items are being ordered, a field that displays the total number of items being ordered, a field that shows the total amount of the order (all items are $19.95 each and there is no sales tax or shipping charges). Also nobody will order more than one of each item. I also need a field that automatically displays the words "Bonus #1" for orders of 3 items or more. Another identical field that displays the words "Bonus #2" for orders of all 12 items. Both fields can display the bonus message when 12 items are ordered. I need a calculation that deducts 10% of the order when six or more items are ordered and the amount of the deduction would be displayed in a separate field, plus the "Total" amount of the order would reflect the deduction. If all 12 items are ordered then the above field would deduct 20% of the total order and that would be reflected in the amount of deduction field plus be reflected in the "Total Order" field I also need 28 bit secured ordering plus a submit button. I have already created the top part of the order page and will provide that to the winning bidder.