2 page Word document creation from a current Excel form.

I have a 'reference request form' in Excel that we currently print off and post to ex-employers of the candidate.

I would like this in a MS Word document that can be emailed, completed and then mailed back to us. I don't have the knowledge to make this happen without the formatting going wrong. I guess it needs the whole document locked down other than certain fields which the recipient will complete. It's two sides of A4 with one jpg on it.