Graphic Design Form Creation

I'm looking for someone to turn the provided word form into a professional-looking and attractive form. All the logos and pictures need to be replaced. The resulting form will be a paper product so it should be easy to write on and navigate. The intention is to print this onto a notepad so please leave adequate margins.

Dimensions: 5"x7"
Sides: Front and Back
Format: PDF and source file
Allow for at least one revision
Turn around time up to one month