New peogram needed

OK i was wondering if some one could start me off on making me a simple program it will have a few text boxes and you have to be able to print them

i need these text boxes
-------------------------------------------------------------
Ebay item #
Other--Large text box

First name
last name

street address
city
state
zip

street address -------- yes a 2nd one as well
city
state
zip

name on the card
credit card #
cc ex date
credit card security #

Phone number

Notes--large text box
-----------------------------------------------
and i need a print botton


if this can be done that would be awsome let me know what you guys think

Thank you soooo much
-Dan

Please find the code attached with this reply.

Hope this is what you needed.

Regards,
Raman

thats awsome thanks soo much