Crypto Currency Form

Can you have this done for me in a couple of hours /asap? I need a crypto currency converter from $USD to Ethereum to OUT And then my form catches the resulting coversion of Etherium to display and submit in a modal popup. After person sends ETH to account a record is shown in history of transaction of account with amount ETH sent and "to" address directly from form and then possibly api to [login to view URL] grabbing all info of transaction and putting it into historical record. I also must be able to change value of OUT coin (since it is mine). I already have historical database in place. Thanks