.pdf wizard needed to convert a form into a fillable .pdf form

Design details: Hi,

I need a form converted in to a fillable .pdf document that allows our clients to complete the fields and email or print and post a completed form back to us.

This needs to be finished to a high standard and I have attached an Example of how the .pdf form should work aswell as the actual form that needs to be converted. The .pdf needs to be supplied in an unprotected format.

UK based bidders preferred.

I look forward to hearing from you.

Regards,

Gillian
Ideas for the visual style: As attached
Extra notes: