Adobe PDF Form Creation

Job ID: 38612378

Budget: $30 – $250 USD

I'm looking for a professional who can create an Adobe PDF form for a service ticket used by field technicians. This form will need to capture several specific details and have additional fields.

I've attached what I need below. I need them to be able to fill this out, and email it out to a single email with a click of a button.
Is there a way to do pre-filled options for the customers/addresses?