HI,
I can ode and make the form like attached png and also fulfill your requirement as I am a professional WordPress expertise.
With 5+ year of working experience, I have always offered my best quality work.
I am new on freelancer but I have the positive attitude toward work.
Money does not matter for me I just need long-term business relationship and the good review from you.
Hope to hear from you.
Thanks,
Aditya.