Form needed

I need a page with a simple form on it that will work with <[login to view URL]> see samples here.... <[login to view URL]> user should be able to choose quantities of tshirts they wish to buy in what sizes and color: SMALL MEDIUM LARGE XL 2XL 3XL 4XL 5XL White Grey Light Yellow Light Blue Light Green Red Bright Yellow Dark Blue Dark Green Black Value associated with SM-XL White is $7 Value associated with SM-XL Grey or Light color is $7.50 Value associated with XXL-5XL is $1.00 more to any color Value associated with Dark Shirts is $1.50 more to any size All values should be passed so mal ecommerce can generate a total for the order. <[login to view URL]> and [login to view URL] will be helpful. post goes to: <[login to view URL]>