Creation of website form

I am in need of a custom built enquiry form for an existing website. The form needs to be used for customers requiring a quote for a taxi ride to include all necessary information. The form should link to a map so the customer can also the route. Once the form is completed the customer submits and we receive an email of the full requirement and we can reply to the email with the price.
As a reference www.Clovercars.com have a booking form from which the inspiration has come from (we are not this company so please do not contact them)