Need a quote form built for a website

Note: Posting this request again, as the person awarded the contract seems to have dropped out of PPH and is no longer responding to requests. Please don't bid on this if you aren't serious or have the time.

As soon as my escrowed funds are released from PPH (which should be 3 days) I need to award this project and get it going.
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Need to build a form similar to the one at this website; http://feedinginnovation.com/request-a-quote/

Would want to have a certain amount of information collected before the form. The part I like is where when you click on an option it shows the price for that component.

The form needs to be able to work within the WordPress platform, and of course I will need to be able to update the pricing on the components as my prices change.

The form will also need to be able to create some type of report so I can see who has requested a quote and compile that info into a spreadsheet.