Custom press release builder form for wordpress

We need a professionally designed press release builder for our wordpress website. We want the form to be polished, professional and very easy to use. Probably looking for something also utilizing AJAX or jQuery, but we are open to your ideas and suggestions too. Form features: Form collects the following: Press release headline Press release body Option to upload a photo Option to include video embed code Keywords Contact name, phone, email address Form requires payment (credit card, paypal, etc) Form automatically prepares formatted press release and preview before submitting. On submit, form submits press release as pending post in wordpress. Form needs to validate. Polished, user-friendly design is very important. Please include examples or links to similar forms you've created in your bid/PM. We are currently using this wordpress theme: [login to view URL]