Hello and thank you for your invitation. I can design the required form for you as per your specifications. However, you should be informed that this functionality requires dynamic pdf, designed in LiveCycle Designer. This pdf will be only compatible with original pdf products, such as Acrobat or freeware Acrobat Reader. This file will not work with any 3rd party pdf viewers and therefor you can't fill it on tablets or handhelds.
This is what you need to consider before making a decision to use dynamic pds. I hope this helps, please let me know if you'll have any further questions.
Best regards,
Sergiy.