Develop an order form with online payment option

I need help in developing an order form for a food delivery website. Some specific requests: 1. Needs to provide a calendar to indicate when they want their food delivered. 2. Allow for a free meal on their first order. 3. Allow for advance orders for multiple days. 4. Link to merchant paypal account and online payment. I don't need it to be too fancy, but I need it to be functional. I need this to be turned around in 1 week. Please let me know if you can do this and if you have questions.