Code One Order Page with few form fields

I need PHP/JQuery coder who can code order page that have only few input fields. I have already coded first page that will collect some data from user, so I will pass three (3) variables to this page that you need to code. I have attached the PDF file with my drawings on how I need it to look like so please take a look at this before bidding. The page is quite simple with around 7 input fields. First two input fields will only need to GET values from previous page. The third will be ReadOnly field and it will be connected with slider which will allow user to choose values from 100-100000 allowing user to increase them by 100. When user choose this value from slider it will show up inside ReadOnly field. Fourth field will be filed where user can enter a simple keyword. Now the most important part is a button that allow users to create field #3 and #4 again with a slider where user can enter another keyword and use slider to choose the # of visitors. The fifth field will be select menu with two values. The sixth and last field will need to show the price. The price is calculated by summing all #3 field values and multiple them with value that I passed from first page. This is a short description of what I need, but will be with you on Skype all time to help you out and guiding you. When bidding, in your PM include word "CODING" so I know you read this text. Since this is quite simple project my budget for this is $40, however it will lead to more projects which will be awarded to you if you do this correctly. Cheers!