HELP!! How to create an affiliate form with refferal code?

Hi, i'm running affiliate marketing site and need to create form like this with my affiliate code.
Now, i'm using redirect to official site with my affiliate code.. (So they register in official site with my ref code)

What i need (they register in my website): by making a form like the screenshot below for sign up (with my refferal code) in my website..
then after they finish sign up, redirect to offical site are okay

Just saw this, if you still need help feel free to message me!

Maybe better in Hire a freelance section?