Tera Wallet Add on simple form plugin wordpress

We need a simple add on plugin for tera wallet. What we need is simple forms where customer will enter the number they want to redeem and then click on pay and money automatically deduct from the tera wallet money. For ease to understand it should looks like given pictures at front end and what we need at the back end is. id- User - Amount - Number - Status- Date and time/ - Action (see in picture admin need to approve it) The numbers customer is going to choose date time and customer email that detect automatically because only online customer has access to the tera wallet. Also data can be downloadable for admin in excel file. Before approve customer can edit or change number but money should deduct on the first hand if cancel by admin money return to wallet otherwise money should not remain. for silver form customers an enter as many as numbers they want for gold form only 5 numbers should allow. for Dimond form only 3 numbers allow at the same time. Once customer going to enter number and amount there should always second empty same fields remained you can see in given picture but for 5 field form after last field means last no more fields to show same for the Dimond form. There should always money sign there in the amount box that can detect from the wallet current money because wallet money sign can be changeable like dollar to euro or any other currency. At the end of form small description and two empty links that can manage by admin at the back end enter URL because all are different buttons different URL need for each 3 forms 6 buttons and 6 are different URLs.