Recommendation and Implementation of a Joomla Payment Form

Our website is created using Joomla. We would like to create a payment form recommended and implemented. This form is not a checkout or shopping cart. Our customers are issued invoices and this would be where they would be directed to pay. This payment form has to be integrated with our merchant accounts are from either TD Canada Trust and Moneris (Canada). Some of the fields that need to be entered are: Name Address Telephone Invoice Number Date Drop down Selector Amount (allow user to enter amount) Credit Card Number Expiry CVV Please make a recommendation of the extension you think would be suitable.