Create Simple Word Doc/PDF

I am looking for someone to create a word doc (that will work on Mac & PC) from the basic drawing I have attached. Black on White. Logo in corner. Writing to be non editable but space to fill in information. Please see attached basic drawing and you will understand. Simple and easy job. (Logo zip file attached also. Use Black and White) I have shown where the blocks should be 1 line, 2 lines or 3 lines. The writing I have put in needs to be non editable but the blocks after the writing will be filled in by clients. If any questions, do not hesitate to contact me. Very simple, quick job.