How do I create this in HTML (PHP)

Customer Information Your Billing Address: Your Shipping Address: Use Billing Address First Name: First Name:* Last Name:* Last Name: Street Address:* Street Address: City:* City: State: State: Zip:* Zip Email* Email: Your Shipping Method: Your Payment Details: Ground (0.1% * Order Value) Credit Card Type: Visa Card Discover Card O Master Card (0.2% * Order Value) Air (0.3% * Order Vahe) Overnight Credit Card ** Expiration Date (mm/yy):* Review Order