FABRIK in Joomla 1.5

I have a site setup for creating database/tables/forms through FABRIK in joomla 1.5. I also have mpdf incorporated to help generate custom well designed pdfs from the input. I need to create the following form and make sure it outputs the pdf in the way it is showing in the attached PDF. The process is all set up, just need to create the form and template for it in Fabrik and create the template for the PDF output and Form Edit. I need this form created and have the templates made ASAP. If you do well on this form/template/pdf output, there will be more forms I will need.