iPad HTML5 App (Enhanced Form)

I need for someone to create for me a html5 form, optimized for the iPads resolution. The app must do the following: -Capture 5 text fields, and 2 numeric fields (such as telephone) -There is one special field for adding tags. Tags are organized in categories. There should be a text field to add new tags. -Capture the device's geolocation under a specific accuracy -In case the geolocation can't be captured then the form must allow for it to be typed in -In case there is no 3G the entry must be stored locally -Allow to take and store a picture from the device's camera -Results should be delivered to a web service