Vehicle Shipping Quote Generator for joomla website

I need a script that will do the following: When user visits the page, they see 7 fields: 'From Zipcode', 'To Zipcode', 'Vehicle Year', 'Vehicle Make', Vehicle Model,' Open/Enclosed,' 'Operable/Inoperable' and one button would trigger the action. This action would retrieve real-time shipping quote information for transporting a customer's vehicle from any point in the country to another. I would like this quote generator to be very similar to this website: [login to view URL] When customer clicks on the pick up they want to book, it will bring them to a page that asks for more information: Your Contact Name Your Contact Number Vehicle Year, Make, Model Pick Up Contact Name Pick Up Contact Number Pick Up Address Drop Off Contact Name Drop Off Contact Number Drop Off Address Date vehicle is ready for pick up Other Vehicle Notes They will then be able to click BOOK ORDER I need this project to be working on my JOOMLA website My budget is $175 and need it ASAP. Thanks.