Create an e-pinion page and payment link on my website.

Require a page on my website ([login to view URL]) where clients can submit and get a quick opinion by email. The way I envision this is that the main page on my site would have an e-pinion box that you click that brings you to the e-pinion page. The e-pinion page has a section where they enter an email address and then a section where they explain their situation and ask their question. There would then be a submit button they press to submit it. When the button is clicked it brings up a payment screen that has the payment amount entered. They make the payment (by credit card or paypal or if there is any other way?) and once it processes there is a notice that the question has been submitted for a response. The page would have instructions on it for using the e-pinion process, conditions, cost etc. The page would be distinct from the other pages on the website ie it would not have the call to action box or other side bar boxes that the main page and other pages have. When you submit your bid please indicate what you see the solution to this to look like so that I can choose the best fit. If there is another way of doing this I am open to suggestions but this is the project as it is for now.