JotForm is a free online form builder which helps you create online forms without writing a single line of code. No sign-up required.
We believe that if one user has a question, there could be more users who may have the same question. This is why many of our support forum threads are public and available to be searched and viewed. If you’d like help immediately, feel free to search for a similar question, or submit your question or concern.
Sorry but you can't convert a .doc file into a form in JotForm.
However, if you have an existing PDF Form (with the same format as the word doc you included on your screenshot), you can make it fillable and submittable by using our Fillable PDF Form Creator
1. Just go this page http://www.jotform.com/fillable-pdf-form-creator/
2. Click the CREATE A FILLABLE PDF FORM button
3. Click the UPLOAD button on the Convert PDF Form section
4. Enter your email address, upload your pdf, then hit SUBMIT. You will be notified via the email address you entered once the form is ready.
Keep in mind that the steps above will only apply to you if and only if you have a PDF version of that same word doc you attached.
If you don't have one, it's easier to just manually match the fields from your doc and create the form from scratch, compared to creating a PDF > then convert it (which requires more work).
To get you started on building your form, I recommend you go to our User Guide compendium:
In case you stumble upon an issue while creating the form, don't hesitate to open a new thread so we can assist you.