Create web form for output to a searchable Fusion Tables Map

I need someone who can create a form that I can place on my wordpress blog (or external site if needed) that will allow users to input their data (location, contact details, as well as a series of checkboxes). I would like their data to be available on a searchable (reasonably detailed search) Fusion Tables map. Once created, I need to be able to modify it as needed for the project (form fields and display options on map) I am reasonably tech savvy. It seems pretty straight forward to do, I just do not have time right now for the learning curve. Not ready to start until June.