Build a form

This project requires a non-WordPress, responsive form for a small weekly newspaper classified advertising section that does the following: 1. Provides a multi-date-selectible date-picker for customer to choose the upcoming Wednesday -- or several Wednesdays in advance -- where his classified ad will appear. 2. Contains input fields for name, telephone, and email address (all required). 3. Presents a validating text input box with a counter that displays, in realtime, the number of words typed. No input allowed beyond 80 words. 4. Presents a "next" button. Now the script confirms if the ad is either 1-40 words (one fixed price) or 40-80 words (another fixed price), and displays the amount due. Also needed at this step is an "Edit ad" button to revise any input field if desired. 5. Payment option buttons: a) direct link that transfers the amount due to PayPal shopping cart, b) invoice requested. 6. Captcha element and submit button to finalize the sale. Each data submission is immediately emailed to admin, but it is also added to an accumulating database and overwrites a weekly text file that is archived on the server. Admin will download that file as required. The accumulated data must show all ads to appear in the next edition and their payment details. For an example of this, please refer to the attached text file. It is not required that the script checks that payments are actually made. That is done independently. But it must indicate when a prior payment was recorded for this ad as indicated in the final example in the attached text file. Obviously any ads ordered for more than one issue must continue to appear in the data on their CORRECT DATES until their quantity expires. Those dates might have been ordered by the customer to appear over alternating future weeks. In other words, they're not necessarily continuous week by week. Ads of this type are not submitted every week, but rather they are "remembered" from the database when originally posted. They should automatically become part of the text file at the start of the week that lists ads meant to appear in that specific edition. No totals, monthly reports, or history lists are required. Admin must be able to delete any ad in the database, thus ending any future appearance of that ad for publication. No other data amendments or computations are needed in the backend. As stated above, there is just one archived text file for each week, and it contains only the ads to appear in the next publication. The current text file for each week must overwrite itself whenever a new ad is submitted. That text file closes forever and a new text file begins to accumulate every Tuesday at 12pm for the following seven-day period. No aesthetic styling is required. Admin will do the final styling of the form so that it fits with the branding and general theme of the website.