Create Email Opt-in Extra Step (Survey Form Pop Up)

(Note:All applications that do not start with a clarifying question will be ignored. If you have no questions, then start by explaining how you would solve the problem, or show a similar previous work you have done. Thank you for your interest.) Create a script that adds a step in my optin form like this one: Current flow: -user clicks button -pop up asks for name and email -user is directed to another url, and he is added to active campaign Future flow: -user clicks button -pop up asks for name and email, user clicks continue -pop up asks to select one of 5 options, user clicks option => THIS IS WHAT YOU HAVE TO CREATE (see sample attachment screenshot) -user is directed to another url, and he is added to active campaign with the tag word of the option they selected Note: My website is using wordpress ThriveThemes and ThriveForms