How to integrate a form like this?

[remoz]

Hi there!

I would like to create and integrate that specific Payment-Form, shown below:

Please notice the options:

1. to enter on the website itself the Credit Card Information
2. to add an additional Service (2 month VIP)
3. to agree with the terms and conditions

Question:

How can you create such a form and integrate it on your website?

I am using WordPress and I am also willing to use Plugins, etc. What ever get's the job done.

Thank you very much for any little help, appreciate it!