Customize a 6 page form for medical website

Customizing an online and coding it to where it can be fillable. Here is what the form contains: Name, address, insurance info, check boxes (like the sample forms I have added). (The sample forms are similar to the originals). The form is 6 pages. A signature is needed at the end of the form. The doctor will purchase a tablet (Android or Mac) so his patients can fill out this medical form in his office, and also sign their signature using a touch screen tablet stylus pen. There should be a send button where the files will go to a secure location where medical staff can access them. Developer should be familiar with security protocols and have a good command of English. Sample work is a plus. You should tell us something about yourself, your experience and why you would be a good fit for the job. We just want to get to know you a little better. Should also have an eye for design. We need the form to look exactly like the ones we will be supply. Once I find the right developer for this project, will present the info to the client and if he agrees and pays, we will move forward. We do not have a budget in mind so just tell us what something like this would cost. Remember you are not designing a new website, you will be developing a customized form on an existing website.