Create an online application for customers

I am looking for a developer that can create an online application with a certain set of questions for potential customers to apply for program membership applicable to the product we offer. The application should do the following things: -Be able to determine if an applicant is eligible for the program based on the answers to certain questions. -Store the application in a database/Excel file/etc. once a customer clicks on "Submit" (I am looking for a recommendation of the programmer as to the best way to direct and store this information so that it is accessible by our administrator). -If the applicant is eligible, the "Submit" button should send the applicant to a new page where they can enter payment information. -If the applicant is ineligible, they should be directed to another page (creation of this page and payment page are NOT part of this project). I am looking for a form that can be incorporated with the theme of an existing website if possible. The application should include a combination of text boxes, check boxes, drop-down menus, etc. that would best represent the PDF version of the application (file attached).