174635 customer gift page for web sit

We require a new page in our web site to allow selected customers to select a magazine gift subscription from a list of magazines on the page. Attached is a picture of the kind of thing we require. The customer ticks a box to indicate which magazine they would like. The title of the magazine is transfered to a form script, the user then inputs their address and details and the subscription is then processed manually. The subscriptions will be purchased from [login to view URL] from the gift subscriptions section there are about 160 titles to choose from. So basically the customer makes a selection and then fills out a from with their name and address and the details are then emailed to us for processing.