Design an Advertisement

Hi, the project I have in mind is to develop an interstitial rich media creative which would have a form built in. The idea is to run a survey campaign through mobile ads which would let the user fill and submit the form within the creative itself without having to go to an external landing page. The questions would appear one at a time (with next and back buttons) and I would like to have the option to chose between single choice(radio button) and multiple choice(checkboxes) for the options. And finally, there should be a submit button which would return the creative ID(some random string in the tag), timestamp and all the options chosen. Just a simple design, mostly text and a logo on top. I'm choosing to go without any ad servers like Celtra or Doubleclick because of the simple design I have in mind. No need of any click or impression trackers. The ad-tag should be compatible with the major ad networks.