create a simple Wordpress/WooCommerce Payment module to accept reload card codes as payment for Bitcoin

I need a simple, form-based payment plugin for Wordpress / WooCommerce that allows a customer to pay with a Greendot MoneyPak, Vanilla Reload, and several other reload products. It should really be a quite simple code, as it is really nothing more than a simple form submission script that includes a button to upload a copy of their purchase receipt for the refill code that they are providing us. The plugin needs to appear as just another payment option when the customer reaches checkout. There are no APIs, callbacks, or gateways to access, just the payment information attached to the order created by the system which we will manually verify upon receipt of the order. This plugin needs to appear alongside any other payment options at checkout and must function seamlessly with the Wordpress/WooCommerce platform. This option should have just one radio button in the checkout options page titled 'Pay by Reload Code' (and possibly have several very small logos next to it similar to the way PayPal has small images of the credit cards it accepts next to their option. Once this option is selected, the next page (after selecting this payment option) has 6 pieces of REQUIRED data and a couple of optional blanks: REQUIRED: 1 - a drop down box that lists the various reload types and requires a choice of the one to which the reload code applies. 2 - The EXACT $ amount of the reload card. 3 - A space to input the unique reload code. (usually 10-15 alpha-numerical digits) 4 - A space to input their Bitcoin Wallet Address. 5 - Email Address 6 - A button used to upload a copy of the purchase receipt for the reload. OPTIONAL: 1 - Name 2 - City, State, Country 3 - Phone Number It is important that all of the fields are properly formatted so that they interface with the WooCommerce order platform. Thanks for you prompt response