I have a word document with the fields needed in my form

I need help with setting this form . Can you assist?

We can help, but that would depend on our availability and the volume of support requests we receive within the day. You can send the file to support@jotform.com referencing this thread ID #1506224. 

We suggest checking our form builder and explore the field types. I'm sure you can do the form alone. The form builder is very straightforward and doesn't need technical knowledge with HTML to build a form.