Design form in Chumpsoft phpQuestionnaire

Hi, This project is to design a template form that looks almost exactly or better than the attached form (picture). We use a software call phpQuestionnaire from Chumpsoft, and has templates that you can download and look at before the project. It requires basic graphic design and html. The hard part is making sure it is flexible to fit different question sizes beyond the questions below, but we can discuss this. I will give access to survey software once the project is awarded. Been doing this a while. No East Indians, small project so full escrow, and release after. +5 rating or more only. You know the rest.