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The Online Store does this very easily and more, giving lead times if required. is it this product you were referring to? This would be the most appropriate way to set this up. have a look at the link to see the description and some short video material on how it works and is set-up. This can be subscribed to through Yola directly.
Another option for a small number of items is something like Jotform which can easily be coded to this end and also can allow payment through a few gateways if required.