[WTB] Simple PHP/or perl script order form

[zer0]

Need:

Form that lists 3 products
Gives a couple price breaks depending on qty ordered (0.1 - 100)
Example 0.1 to .6 = *$100, .6 to 1.00 = *60 ect
Adds a $5 shipping fee

Calculates totals
Display bitcoin pay-to address (i manually change daily, no bitcoind calls)
Asks for email addy, shipping address and GPG reply key (optional)
Has captcha at bottom
Script encrypts form with gpg pub key on server
Sends email
Deletes history

No javascript or database if possible
PHP or Python/Perl w/e you can do. Running deb squeeze vps

????
that's it

pm price or here
thanks :D