Assessment tool

Need the attached form to be re -created and converted to interactive, submitable form to be downloaded from my site as well as to be included in my new E-book: 1. Will be included in the E-book and must have the capability to be submitted from the book 2. Must be branded as per web site and (color scheme and Logo) 3. Images provied are to be included (logo and professional picture as well as my credentials that will provided to the bid winner. 4. Form provided has an error on one of the drop down boxes that must be corrected. Will discuss with winner 5. Many more to come for the right bidder