Tiny form fixes. Easy review!

Hi, I have a form located at [login to view URL] that sends the form info to my email, imputs all the form info in a database, and totals the package+any addons that the customer selects and creates a paypal subscription button after customer clicks submit. Somehow i messed it up and these are the things i want fixed and added. 1. I need the form's functions fixed it no longer totals to paypal payment but even if the person selects a webhosting plan it still redirects them to [login to view URL] but only a custom plan should do that without a paypal button first. 2. I need to add two text fields to the form which will submit with the rest of the form to my email and to the database. I need a section that says Nameserver1: and Nameserver2: 3. There should be seperations between the contact info part with the header in bold: Contact Info. Then the next section should say: Plan Information with only the Domain name field, the plan drop down and the option to add direct admin. Then the next section after that should have the two nameserver text fields and should be headed in bold with: If Only Registering A Domain. The next section is the one that includes the password, username and domain/subdomain fields headed with: Account Information and finally the last fields are already headed. :::NOTE::: Max budget 10-15$!!! Nothing over this since the form is already created!!! I will use you to integrate the form into my design so don't bid if u can't do that. I will pay an additional 10-15$ for the form's integartion. Please ONLY bid here for the three fixes above. THanks!!!!