Here's an example of the form I mocked up:
https://docs.google.com/forms/d/18Mho396bPMUudpjufGDrEJm449eDctI2XMUv0cR3fvI/viewform
Here's an example of the form I mocked up:
https://docs.google.com/forms/d/18Mho396bPMUudpjufGDrEJm449eDctI2XMUv0cR3fvI/viewform