Small iOS App Development for iPad 3

I want a small app for iPad 3 (iOS v9.3.5, Jailbroken). The App would collect guest's feedback via a form & store it in excel, csv, etc format that I can later access. I do not need the app to be uploaded to the store, just to run on my iPad.

Do let me know if you can develop it & what will be the charges for the same. Thanks!