Stripe.com Phone Order Page

Hi, I run a business and I need my representatives to accept phone orders without access the [login to view URL] payment gateway account. Integration Documentation Information: [login to view URL] I need a simple html/php page that will have the following fields First Name Last Name Street City Zip Code State Credit Card Number CVC EX Month EX Year Select Subscription (this will be a drop down menu) Submit Clear After the form is submited it suppose to output an answer if transaction went through or got declined. If a transaction declined the phone rep should be able to re-enter the information. If a transaction went through phone rep will see approved and a form will reset to empty Also there should be a clear button to clear the form. Select subscription is where rep selects a monthly subscription this will be matched with [login to view URL] by using having a php file with ID, Name, Price that will match the plan on [login to view URL] You can get a demo account here: [login to view URL]