How To: Survey, Poll, or Pledge and show results on webpage

Ok, I’m going to try to explain what I want to accomplish. Hopefully I can explain this well enough for everyone to understand. Maybe there is a plugin to handle what I have in mind?

I run a website for a non-profit organization and what I want to do is setup a hypothetical pledge. I say hypothetical because I don’t want to collect any money at this time. What I want to do is gather information.

I want to be able to tell a story of a project that we have in mind and ask our supporters, if they supported the project how much money would they be willing to pledge, without actually taking the money (hypothetical as I said before)

What I hope to accomplish with this is to gather an actual goal to set for this project at a later date through Kickstarter or something similar.

I would also like to display the hypothetical dollar amount with some sort of progress bar and also possibly show data from there approximate location (I was thinking just by state)

So the info I need to collect on this pledge, survey, poll, or whatever you want to call it would be their name, email address, optional phone number, hypothetical pledge amount, and state location.

The only data I want displayed to the public would be the dollar amount and a geographical map.

Thanks for the help. I hope I made sense..