Create LaTeX template FORM

I need a LaTeX Template for the following form. You can enter fake data/address/etc such as the given example. The document should be as self contained as possible, if some macros or packages are required that is ok. The document should compile with XeLaTeX and look nearly identical to attached form (except red text and highlighting is not necessary, blue type will do for form filling part ). NEED within one or two days max. Thank you.