Create A Form with Payment Option

I’m not sure if this is an out of the box option, or if I would need someone to create this page.

Here’s the deal:

I have one product that I sell to dealerships with corporate accounts.
I’ve created a simple form similar to this;

SALES PERSON INFORMATION
Name:
Email:
Phone:
Dealership:
CUSTOMER INFORMATION / SHIP TO ADDRESS
Name:
Address:
City:
State:
Zip:

CLICK HERE TO TAKE PHOTO

SEND
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The image and information are then sent to us, we create the product, ship to their customer, and bill the dealership on a monthly bases.
I am finding that there are some dealerships that don’t want to sign up, but sales people within the dealership that would like to use the service.  Thus, I would like to include an option at the end of the form, for customers to Pay Now via credit card, or bill Corporate Account.

Thanks for the support,

Bill, Peace