Woocommerce payment form

I need to create a payment form in woocommerce so customers can enter the following details:

Name:
Address:
E-mail:
Account Number :
Customer submitted Payment Amount:

The form then has to submit to the 'FIDELIPAY' the payment gateway already installed and setup in woocommerce (Fidelipay hosted works by sending the user to Fidelipay to enter their payment infofidelipay-hosted.phpmation).

Here is an example of what we require: http://www.bellequine.co.uk/pay-online however this example uses worldpay but we need to use FIDELIPAY https://fidelitypayment.co.uk/fidelipay-gateway/ Note. the FIDELIPAY woocommerce plugin has already been installed.