This is a simple loan application for lenders in the Philippines. The slider simple suggests a repayment amount, they then have a multipart application. This form works FOR THEIR BUSINESS. It probably isn’t suitable for yours but it can be easily adapted

I want to borrow: 123
Payment Terms
Monthly Repayment
DISCLAIMER: Quoted loan amount and monthly amoritzation are indicative only. Borrowing has a monthly interest rate of if loaned over . Final loan amount, monthly amotization and applied rate shall be confirmed in your loan documents upon loan approval. Final loan approval shall be subject to the submission of required documents and the Bank's credit policies and procedures.