Form for website need setting up

I have a website already selling art, I am in need of a form setting up where people can go on and order a painting with the facility of sending an image or photo of what the would like.

The form needs to be embedded into my current site with a look and feel of the site. The form should consist of

Name -
Image uploader
E-mail address
Phone Number - optional
Size of canvas - with options
Type of Subject - With options
Colours

I have a site with a similar form that i would like to have similar options with maybe a deposit option of payment if possible too.