need help for a template

I need assistance creating a campaign pledge card template for my website

Here is the info:

#CheckYourWords

First Name. Email address. Age.

Location (State/Country/Province).

I pledge to take the #CheckYourWords challenge for the rest of 2019!!

You can add the desired elements to your form, first I would recommend you to register here if you do not have a JotForm account: https://www.jotform.com/signup 

Once you have your account you can create the form, you can add the desired elements and this guide will provide you the details about the available fields: https://www.jotform.com/help/46-Quick-Overview-of-Form-Fields 

Once you have created your form you can embed it following any of our available embed methods: https://www.jotform.com/help/67-Which-Form-Embed-Code-Should-I-Use