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Add-on Store Locator

I have a state based forum, but we are looking for stores inside the state.

I would like a user to be able to submit a store with the following information
Store Name*
Store Street Address *
Store State* (I would like this to be configurable since it's a local region)
Store Zip Code*
Store Phone number
Store Website
Store Hours
Type of store (Store Only, Store && Field, Field Only)
*items are required

After the submission I would like for it to populate a table listing all the entries.

I'd like a google map integration, where the pins are the individual entries. If this needs to wait until after the event, fine.

I'd like to take quotes on budget and price. Please send me examples of your work, and I'm looking to get this done as soon as possible.