Develop Simple WordPress Plugin

I have a web form that has been developed that need to be included into WordPress. Add-in needs to include two components: 1. Web Form. Sample of the form is located at: [login to view URL] User needs to be able to select the fields that he or she wants from a list we will provide for you. (Roughly 10-12 items) For Submit Button Text should be customizable to change what the user wants it to say. Space needs to be made available for a API Key inside the Plugin Configuration Area. User Needs to be able to select the end destination after the form is submitted. (Currently it and the API are variables that are stored in JScript as Variables.) Plugin should have a check box that enables a javascript element that will be in the footer of each page.