Calculator development for a wix website

Hello,
I need a calculator coding for a wix site that is currently getting built for me.
The calculator just needs to take the following information:
Name
Age (55 - 90) selectable on a slider
Address with post code look up if possible
Property value (£75,000 - £1,000,000) selectable on a slider

Calculate - next image is the results, shown as ..... Based on the information you have provided you may be able to release £x - £x

Disclaimer... the above figures are not a guarantee or offer of a loan, the figure given is a guide to how much you could potentially release from your property through equity release. Contact us now for further details.

The results should show an approximate amount of money someone can release from their home with an equity release mortgage.
There is a simple spreadsheet that I can give which shows the percentage someone is able to borrow on their home which is directly linked to their age.

The table is attached for reference, the results need to show the minimum and maximum values in £ for each group

A good example of a calculator that I would like you to use as a guide:
https://www.onefamily.com/lifetime-mortgage/lifetime-mortgage-calculator/

The calculator needs to be able to sit on a wix site and be both mobile and desktop friendly.
The details that someone enters into the calculator must then get emailed to a nominated email account so the customer can then be contacted.

The calculator needs to have a good appearance, the companies colours are pink and grey, if that could be considered in the design


The project needs to be completed asap