Create WordPress review getter page

Create wordpress page for my website to get reviews from my customers. Very simple: Five stars in the middle of the page in grey color. When user hoover mouse over stars it become gold color. When user clicks on star window will pop up, depend on star user click. If user decided to rate from 1-3 stars window pop-up with contact form where user can live and send message. If user rate from 4 to 5 stars other window pop up where user can pick website by clicking on logo of website and live a review (google, facebook, yelp, angies list with direct links to review pages of this websites, so when user click on google logo it will take him to my company google review page). My website is [login to view URL] and can run prettyPhoto, is a jQuery lightbox clone. But you decide how you want to do it. It's better if it will be html code for me, with customizable list of review sites, place on page where I can place logo of my company and encouraging message for users who want to live review. You can see attached examples