I need a simple web form (PHP or javascript?) containing a list of checkboxes (53 items, but with the capability of future expansion) and amounts that when submitted outputs a printable list showing just the checked items followed by a set of checkboxes.

For example, I have this list:

Beanz: Key Lime (user sets this to 3)
Beanz: Licorice (user sets this to 5)
Beanz: Peach (user sets this to 7)
Beanz: Strawberry (user sets this to 9)
Caramels (user sets this to 2)
Mallow Sampler Pack (user sets this to 10)

Each of those needs to be "checkable" with a numeric field. When the form is submitted, it should return a list like this, suitable for printing (and with _ replaced by an actual box):

Beanz: Key Lime _ _ _
Beanz: Licorice _ _ _ _ _
Beanz: Peach _ _ _ _ _ _ _
Beanz: Strawberry _ _ _ _ _ _ _ _ _
Caramels _ _ 
Mallow Sampler Pack _ _ _ _ _ _ _ _ _ _

I know it sounds simple, but I'm busy making the candy and don't have time to script it myself, let alone the brain power to puzzle it out.

Payment would be via PayPal, of course.

Thanks in advance!