Write some Software

Hello, I need someone to make me a small add that I can use for google adwords. The add needs to be a static photo and when the viewer sees it changes in the sense that a form appears on top of it and this new form asks the user a question and the user needs to answer by moving a slider - see the example inside the attached file. The answer is collected into a back-end database (or google drive etc.). I don't know if this is possible but I know that adwords accepts html5 files so maybe someone knows how this might be done. Thank you in advance for your interest.