Custom-Built Animated Web Contact Form

Looking to update my wix website with a new Contact form (custom built not designed on wix) - Specifically i want to code a custom-built contact form. This form will be both mobile and pc opimised. Im planning for this form to have it hosted on a server and have the custom code posted into wix to bring it up.

This form will have perks for every detail the lead provides (name 10% discount), (number extended warranty), (email fast track order), Suburb Free Measure, To leave a message or no message and submit.
This contact form will also have the perks listed and slightly transparent then when the details are filled they have a small animation and are unlocked (possibly add a subtle sound to this action also, want an appealing small bit of movment to signify that they have unlocked that perk). This form will need optumisation and rules set in place to have limitations etc. All new leads will need a summary sent to our email address.

We are a blinds business called Real Blinds -> www.realblinds.com.au