Clone a Simple Script

Thanks for looking. I need a simple script created that I can upload into a wordpress page that does the exact same thing as: [login to view URL] 1. It needs to have a drop down menu with the same coins listed - needs to show image A quantity box (number of coins) A dynamic ability to include the spot price of silver An a submit button The formula is displayed on the answer page. Again, it needs to be something I can simply (or you) can upload into wordpress. Thanks