Add method of payment for Magento

We need to add a method of payment in Magento. This method will allow buyers to fill out a form for finance purposes. We will provide the fields for the form. It should be simple: name of bank, customer name, address, etc etc... The form should allow buyers to select a bank: each bank will have a different form. We should get the completed form by email once the buyer submits it with all the required fields. If you can any additional features to this process let us know. Thanks, chatwin