Create PHP 'Request Service' order form for my website

I need to create an easy to use order form for my chauffeur service's website: [login to view URL] There will be a text link on the navigation below the masthead that says 'Request Service', next the 'Compare Our Rates'. This request Service will be a secure form that visitors will fill out with their credit card information and the specifics of the service they need. In total, there will be about 15 - 20 fields visitors will fill out, including credit card info. Errors and omissions in the form need to be highlighted and the form will not submit without 'required' fields filled in completely. Once the form is filled out correctly, it will be emailed to me for processing, and a 'Thank You' page will appear for the user, letting them know the form was submitted successfully. I will provide all the text and layout, you will implement it so that it looks neat and professional, like this: http:[login to view URL] Thanks!