Hope I can get some help here.

I need to create a PHP form where clients can order online services.

For better understanding I have included a URL: http://www.activefilings.com/forms/order.php
This is exactly what I need if any of you guys can give a hand I will really appreciated.

Requirements for this form:
Use is able to save the quote
Use is able to register
User can retrieve quote after they log in
Form can use a secure site
Payment can be process offline / or Papal

Please let me know an estimate

Thanks in advance for your support.