Paypal Order Form

I want to create a paypal order form whereby, before somebody makes a purchase they have to include their Name, Email and some other variables. Basically, things that are not included in standard paypal info. I would then like this info to be emailed to me. This is what I want it to look like [login to view URL] In the payment details section, I would like for the user to add in their credit card or paypal account details. I would also like for something similar to this date image. [login to view URL] Once the user has made payment, they are taken to a confirm page. Similar to this: [login to view URL] Once confirmed they are taken to paypal, once payment has been made they are redirected to a thank you page. I will finalize what I would like the form to look like and what needs to be added with the coder, but that's the basics. Also, this is what the email I receive should look like: [login to view URL]