Bootcamp dietary requirement request form

Information for the business: Thailand fitness bootcamp
Industry: Lifestyle/Travel
Design details: I would like a simple dietary request form. A PDF please so people can fill it in and send it back to me. So it needs to be fill able on screen. So people can type straight from their computer.

Which says

If you have a food allergy or particular dietary requirements please complete this form and return it to the Radiance restaurant at the Spa Resort Chiang Mai using this email address xxxxxxxxxx@xxxxxxxxxxxxxx.com

Name:-

Date of stay:- from --/--/-- until --/--/--

Then a big box which says
Details of dietary requirements.

I would also like the logo somewhere which I have attached.
Content on the front/back side and body: Bootcamp dietary request form
Ideas for the visual style: simple
Extra notes:

Should only take 10 minutes, just a quick 10 minute job for someone that knows what they are doing.