Local delivery

Happy New Year, to all

I wonder can someone have idea for local delivery ( local towm) I am run florist shop.

for example input field

Date for delivery...............
To..................
address..............(local adrress)
wish .....happy b'day
from......
...........
..............

thank you

Here is my extension :http://www.opencart.com/index.php?route ... on_id=4623

You can make the changes according to what you want. It's flexible.