Build a Form in React | super simple | ASAP

Hello,

I need someone converting a simple form (see pdf attached) into code.
I need this ASAP, so if you could do it today, that would be great!

Please build the form based on the following PWA that is using React:
https://github.com/jzrskc/react-pwa-form-app

Requirements:
- styling should look like the pdf
- responsiveness should be given
- result send out in nodemailer
- if you know how to add signature, that would be amazing, but this is not a must

Thank you!