Simple form add on for terawallet plugin -- 5

We need a simple add-on plugin for Tera wallet. What we need are simple forms where customers will enter the number they want to redeem and then click on pay and money automatically deduct from the Tera wallet money. For ease to understand it should look like given pictures at the front end and what we need at the back end is. id- User - Amount - Number - Status- Date and time/ - Action (see in picture admin need to approve it) The numbers customer is going to choose date time and customer email that detect automatically because the only online customer has access to the Tera wallet. Also, data can be downloadable for admin in an excel file. Before approval customer can edit or change the number but money should deduct on the first hand if cancel by admin money return to the wallet otherwise money should not remain. for the silver form customers can enter as many as numbers they want for the gold form only 5 numbers should allow. for Dimond form, only 3 numbers allow at the same time. Once customer going to enter number and amount there should always second empty same fields remained you can see in the given picture but for 5 field form after the last field means last no more fields to show the same for the Dimond form. There should always money sign there in the amount box that can detect from the wallet current money because wallet money sign can be changeable like dollar to euro or any other currency. At the end of the form small description and two empty links that can manage by the admin at the back end enter URL because all are different buttons, different URLs need for every 3 forms 6 buttons, and 6 are different URLs. Also has some shortcodes to mention your previous number, your current numbers, etc.