Package Delivery Calculator for HTML Website

We would like a Simple Calculator for customers to get a quote for package delivery for a Courier Company. This is NOT for UPS, USPS or FEDEX rates. We do local delivery and will need to enter our own rates in the calculator. The calculated rate will need to just show on the screen for the customer to see. I have included a Word Document with the features needed. It will need to be created in HTML code so we can install on an HTML website. Ask any questions.