Create a form and popup carrying over shopping cart information

I have a new hotels reservation website that currently accepts credit cards. I want to create a popup for OFFLINE payments using bitcoins. On the screen attached, I want to add a new button "Pay with Bitcoin" and when the user clicks it it will open a POPUP with a form to collect some info from the client: Name, Last name, Street Address, City, Country, phone and email. After user submits the form he gets to a popup with the: - HOTEL NAME, DATE, ROOM TYPE - the total price in local currency (R$) as carried from the area marked in the image attached (TOTAL PRICE) - the price calculated in bitcoin - check box saying client agrees with Terms & Conditions - button "Finalize and Pay with Bitcoin" PRICE CALCULATED IN BITCOIN: - You will need to create a table that I can maintain with the current bitcoin price per (R$) - The price showed in bitcoin will be the TOTAL PRICE divided by the current bitcoin price in the table above. After client clicks finalize and pay with Bitcoin: - There will be 5 hidden different bitcoin address codes and their respective QR codes (static image). - The client will be shown a popup with one of the 5 codes and it is respective QR code - An email needs te generated with the reservation and payment information. - Client will click a button, to close popup and go back to home page. MY WEBSITE IS: [login to view URL] Thats pretty much it. Please take a look at the screenshot.