Feedback App - [Will be run in Tablet]

I run three brick stores. I need to put up a kiosk to gather customer feedback. Will run a browser and run this app in kiosk mode. The app should have the following features! '1. Kiosk Mode [this is not mandatory. i can use some freeware in tablet to run the appln in kiosk mode] 2. Collect - Phone Number, - Star Rating or Smiley styled rating, - Comment/ Suggestion to add - Photo selfie - scan bill 3. If posible configure the input parameters as i have multiple store. So for some store i may need more input. for other store i may need only few input. so plan to set the parameter as scable and configurable. 4. can use HTML5/ jquery mobile or something that can be compatible in all mobiles. [hybrid] 5. Reporting/ Data analyser [Either in the same appln for the admin or a seperate web appln] 6. Reporting data is in realtime in online either stored in Cloud or some web api 7. Email trigger for each of the feedback top preconfigured id.