Integration with FirstData

I want to create a form which integrates with FirstData and collects:

Order Number

Email

Name on Card

Credit Card Number

Expiration Date

CVC

Total Amount

I would like it to look very similar to the attached screen shot.

You can collect such payments with our FirstData payment integration: 

And you can insert email and text field by using the basic fields:

Let us know if you have any further questions.

Thank you!