Created basic web form

Create a form. I would like a web form created. Once created to be generated a pre-filled form auto sent to my email. First to always generate the current date at the top of the form. The user will need to be required to enter the following.. Please enter your First name in the box. (then show a green tick when completed) please enter your surname in the box. (then show a green tick when completed) Please state your registered address as it appears on kimo. (then show a green tick when completed) Please type your registered email address as it appears on kimo. (then show a green tick when completed) Please state you kimo. (then show a green tick when completed) Please enter a moto for yourself. (80 carchers max) (then show a green tick when completed) Once done the user should then click a complete button. This will then ask them to check the information they entered is correct showing the information again. The and edit or continue. They are then asked to digitally sign this info by typing in there first and last name again. Once confirmed the form is then generated and sent to my email address as a .jpg or .pdf The blank form that I want the info to be inserted onto will be uploaded later as its not important at this time. The font required to be added to the form when finished will be tkand that I have attached. If your able to do this please bid.