Build a register form with payment button

I need a template form for registration, below are details. Note: Leave a column for admin to display message for users Mr, Mrs, Dr, Miss, Bro, Sis ( This will be a check box ) Surname: .................. Name:............... Middle Name........................ Email Address.......................................................................... Address:................................................................................. ............................................................................................... State:.......................................................................... Zip:.......................................................................... Country:............................................................................. Phone Number:................................................................. Date Of Birth:........................................................... Are you a Watchman? Or a Visitor? ( This will be a check box and if someone say am a Watchman this message will appear, see below) Fellowship Center:....................................Country:.................. ( Required ) How many people do you want to register? 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ( This will be check box) How many Adult ? between 14 years above 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ( This will be check box) How many children? between 3 - 13 Years 1, 2, 3, 4, 5, 6, 7, 8, 9 ,10 ( This will be check box) How many infant? between 0 - 2 Years 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 ( This will be check box) Note: For adult payment is €100 For Children fee is €50 between 3 - 13 years For infant fee is €0 between 0 -2 years Am paying full amount? Am paying instrumental ( This will be check box) When someone choose full amount then this amount will appear €100 If someone choose am paying instrumental these amount will appear €50, €30, €20 Note: If someone choose two adults it will appear €200 and if someone choose one or two adult with children between 14 year will be €150 The same thing when someone choose instrumental. After registration there will be SUBMIT OR CONFIRM And next page is for payment option where the payza payment button will appear.