Create Shoe Poll

I need a simple form created. I will provide 60 shoe images and I want my view were to be able to select 10 shoes maximum from the choices given. View were the boat then type their names and submit the form after the form is submitted they will receive a thank you message. In the back and I will be able to see a graph of the most selected shoes via rank. I will provide the images. I need the form created now. it's a simple form and I need A URL so it can be submitted and hosted anywhere.. thank you