Classipress Customization - Create Custom Form

The project is to create a custom form on my classipress site. Please, refer the image on attachment for fields details. Also, it´s important to prepare the form to receive other fields in the future. Documentation teaching how to add new fields in the form is required. The purpose of this form is to send an email containing a generic message within form fields to all suppliers for the selected categories. Timeline for this job is 5 days. Please, only bid if you have previous experience with Classipress.