NopCommerce: Custom Product Page - Capture small form Data

Hello, Ok todays project is aDoctorsChoice.com. For this project I would like to start with a nopcommerce full source base. This is a new website. Anyhow for most of the website we can use the stock nop commerce system, however I need help in collecting the data and is playing a sample for the websites 2 products. For both products it's the same process. What I need is a product page that allows the doctor to choose the "prescription pad" style they want and enter the basic info like name and address to be printed on the pad. Then I need to to display an example of what the pad will look like, then when they hit approve it adds the item to the cart with the collected info. Making the sample view Basically I have 4 images of blank pads, so depending on the pad the user chooses that will set the background, then I need your code to collect the address and name, then display it on top of the pad image right in place where it is supposed to go on pad. Then once they see the pas they can approve, the item is added to cart and we use the checkout to process order. I am hoping to have form data that is collected on order info email. I attached the exact details of the shopping process as well as multiple screenshots explain the process. Now I am a developer myself so I can work with you if we need to tweak the design a bit. Just as long as we get this visual approval thing. Any questions please ask, I am looking to start as soon as right developer comes along.