Write some Software / proforma gateway -- 2

I need a portal to input information that will then transfer to my hire agreement. Information that will need to be captured will be: Page 1 Agreement Number ----------------- (Hirers details) Client 1 - Name, Address, DOB, Occupation, Driving License Number Client 2 - Name, Address, DOB, Occupation, Driving License Number ----------------- (Hire Vehicle Details) Vehicle Make Vehicle Model Registration Body Style Transmission Fuel Type ----------------- (Hire Period) Date Out Time Out Date Hire Must end (89 Days from the date of agreement) ----------------- (Charges) Daily Rate Additional Driver Collision Damage Waiver Automatic Charge Tow Bar Charge Road Fund Licence Total Cost Per day Inc VAT Dual Control Charge: Sat Navigation Charge: Hands Free Charge: Delivery & Collection Charge: Admin fee: Any Extras: Any Extras: ----------------- (Statement of liability) This should calculate the figure 89 days of charges ----------------- (Declaration) Date of agreement needs to match Date out (Hire Period Section) ----------------- Page 2 Should never change Page 3 Our reference should match Top of Page 1 (This should match & follow through whole form) Date (This should match date of agreement & follow through whole form) Section (Cancellation Form) This should match the ref and customer information & follow through whole form) Page 4 Hire Questionnaire Our Ref (This should match & follow through whole form) Accident Date - Needs to be input manually Customer declaration Needs to mirror Customer 1 name and address. Name - to mirror Customer 1 name and address. Date - Needs to match date of agreement Page 5 Our Ref (This should match & follow through whole form) Date - Needs to match date of agreement Accident Date - Needs to follow on through agreement Name - to mirror Customer 1 name and address. Name - to mirror Customer 1 name and address. Date - Needs to match date of agreement _______________ All input fonts should be the same and regimented throughout the form.