Hi,
If you have any references then do let me know . I will get the form built as needed.
I am fullstack developer with 10 years of experinace and will do the task as per your requirement Skills: WordPress, Woocommerce, Custom PHP, CodeIgniter, Yii, Magento, Open Cart, Shopify, Responsive Design, HTML, HTML5-CSS3, Bootstrap, Wix. Lets have a discussions. Thanks!"