Need custom form for website

I need a custom form designed for my site that will allow a user to enter their name and billing/shipping details along with credit card payment info. I need this info captured and submitted to me in an email each time an order is placed and I will process the payment info offline after verification. I also need a 'thank you' screen to auto generate that shows the customer their order they just placed. Expert english speakers only, sorry, no Indian bidders thanks. I prefer US, CA, AUS or UK programmers. Gary