I need an application form digitized

I have an application form for an educational company that is created on Microsoft Word (1 page only) that I would like digitized to work on a website, sent by email and contain the ability to be filled digitally without printing either through a landing page or through PDF.

Information such as text, dates, check boxes are what are required for the document.

This is an urgent project. Required to be completed within 48 hours.