I need a fillable online form for my website

My website trekili.com has a trip application form that does not function to the standard I need. The previous web guy did a poor job and was not creative or a lateral thinker. After clients tried to use it, it was found lacking and requiring refurbishment. I need someone who can not only redo the form but who is able to provide guidance and advise to enhance the form so it works seamlessly. You will be able to guide me on layout options that work with the site and on mobiles. As a guide I have attached my thoughts on how the form should be set out. My business is a trekking and safari company. The form is used to gather important information about the clients and it seems prudent to incorporate trekili's terms and conditions in the same location with the ability for the client to sign acceptance electronically. It will need to be emailed to the client automatically so they have their on completion. The form should have an auto fill date. Need it to be as user friendly to the clients as possible so its easy to complete and submit. The form once completed needs to be loaded onto the website and a minor button adjustment made. SEO needs to be considered in the build.