Automatic proxy topsite submitter

I need a script that will allow me to offer automatic proxy topsite submissions. It will need to ask the user for a few different fields such as URL and username and password among others and it will submit the info to the list of proxy topsites I have. The user must be able to chose from 20, 30, 40, 50, 60, 70, 80, 90, and 100 submissions, each having their own price which needs to be paid before it does the actual submission. If the topsite has a CAPTCHA it wants entered it needs to display the CAPTCHA image and a box next to it so the users can go down the list entering the codes and when they hit submit it will put all info entered into each of the topsites. After the user submits it needs to give them a list of the codes for the sites they submitted to. See attachment for setup and some clarification. Im not sure if that all made sense but you should be able to get the idea. Make a bid and PM me with questions. This shouldnt be a hard project and im looking to get it done quick, make reasonable bids.