479589 Contact Form On Paypal Shopping Cart

Hi, i need someone to add a contact form on my checkout page of my site. My site uses Paypal to pay for goods and i want to add a contact form on the checkout page so that customers can enter a shipping address and contact details. Please see attached PDF document for screenshots. This is a very small and easy project so please bid sensibly. If i am happy with your work, it will lead to other bigger projects, thanks in advance...