SOFTWARE NEEDS FOR DOOR TO DOOR LIBRARY SERVICE.

I have a company of door-to door library service for which I need a membership feedback software. My software vendor is Ambuj Sinha (B12004) his blog is http://softwareapplictns.blogspot.in/2012/08/blog-post.html
I need the following specifications in the software:

NAME:
AGE:
OCCUPATION:
MEMBERSHIP CARD NUMBER :
PHONE NO:

FAVOURITE GENRE:

FAVOURITE BOOKS:
(MAX. 5)

TO-BE READ LIST
(here the members will put the books of 5 books they would like to read)

WHICH SERVICE IN ORDERING THE BOOK WOULD YOU PREFER?
ONLINE
TELEPHONE

HOW MANY BOOKS CAN  YOU READ IN A MONTH?
 0-1
1-2
3-5
MORE THAN 5


WHEN WOULD YOU LIKE THE MEETINGS OF THE BOOK CLUB?
ONCE A MONTH
TWICE A MONTH
EVERY FORNIGHT
EVERY WEEKEND

DOES THE BOOK REVIEW GIVEN BY OTHERS AFFECT YOUR CHOICE OF BOOKS?
YES
NO

HOW MUCH TIME DO YOU TAKE TO READ THE BOOK?
1 DAY
1-2 DAY
2-4 DAY
MORE THAN 4 DAYS


ARE YOU SATISFIED WITH THE SERVICES OF THE LIBRARY?
YES
NO