Create a fillable PDF Form - 1 Sheet

Hello, this is a very simple project: Your task is to create a 1 sheet fillable PDF form. The form will will be used by our online customers in the event that they would like to return a purchased item (for refund or exchange). Attached is a template extremely similar to what we need. We ask you to create a form that is exactly the same - perhaps improved design is the only modification to be made. We also don't want to have the exact same design as the attached form is not our form. The file submitted will be tweaked by us later on (ie. adding the proper pictures, and editing the text a little) therefore it must be editable. Your task is only to create a form just like the one attached, with improved design. Thanks.