I want to add a configuration form for a block. The form's style is the following:

    one year (label)    input text box value    eg:$10     
    two years           input text box value     
    three years         input text box   
    500 accounts        input text box   
    1500 accounts       input text box   
    2500 accounts       input text box   
    image:              can upload an image

How do I do it? I should write a module to get that.

How do I design the table, which is used to store the input box value and image value.
How do I design the fields? Which hook should I use?