Custom Product Fields Wordpress

I need a page form or product built to have the following:
receive payments for events.

Here is how I would like it to work.

Selection 1: drop down boxes
Initial Deposit
Secondary Payment

Selection 2: drop down boxes
Option 1 (these will have locations listed)
Option 2
Option 3
Option 4

Selection 3: Drop Down boxes, amount:
$400 Event Deposit
$2,000 Wedding Deposit
Other (they can type in number)

Date Box

Host of Event Name

The amount options must calculate for payment using authorize.net