I need to Create a Form in a Facebook tab that collects Data from Customers

I have a Facebook Page that takes orders from Customers and we bring them their products.
I'd like to have a Facebook tab named: "Submit you Order".
All I need is a Form that takes the following Fields from the customer and sends them to my e-mail in an organized way:
1) First Name and Last Name
2) E-mail Address
3) Contact Number
4) Address:
- Street Address
- Floor no.
- Flat no.
- Area
- City. I'd like the City Field to be a drop down menu that includes all cities in Egypt in Arabic Language. (I attached a notepad with that)
4) A table consists of 7 columns: #, Link, Quantity, Color, Size, Online $Price, Given EGP Price
and 2 rows as a start. In case the customer has more links to order, we need to add a Button "Add Link" to add an extra row

Then the customer submits the form and receives Thank you for your order, You will receive it within 2 to 3 weeks from now.
I need the HTML code to put in the facebook tab application and the .php file and I have a hosting account at ipage.com and it's preloaded with php and mysql so I'll upload them myself.

Please Check attachments.
Thank you in Advance