BigCommerce Custom Form

I primarily need a custom contact form on my site. The fields are: Name: Email address: Street Address: City, State, Zip: Checklist 1) My items are clean and in good condition. 2) None of my items are on the do not send list. 3) I acknowledge I will receive payment once my clothes have sold, with the remainder going to my charity of choice. Pick a box option: 1) Send me a box 2) Request a pick up date (include date) Choose your charity: (these will be icons that will be clicked) 1) Leave it to us Charities: 1) Charity 1 2) Charity 2 (about 15-20 charities for now with the option to add more in the future) SUBMIT Once submitted, I also need a thank you page and an automatic email confirmation sent out to both parties. Let me know your thoughts on timing and rates and thanks a lot!