[url removed, login to view]~rditradi/beta/[url removed, login to view] (or see attachment)
The form is self-explanatory. The small diamond icons on the top right are selectable images, it is one form input. The sliding scales each return two form inputs. The ranges of the sliding scales needs to be editable. Please provide a quote and time frame. Let me know if you have any additional questions.
A similar working version can be seen here:
[url removed, login to view]