Is this form possible through attributes

Hi Guys

I would like to create a form to capture required information from clients and this form will be standard on every product page and must be filled in before checkout.

Just wondering how I could use attributes to get me the same result as the picture of the form I have attached.

Your assistance is much appreciated.

Michael

this is actually what I look for it's answer and I tried all the possibilities. I tried to implement javascript, html form, indirect html form by using ech function and putting <?php in the product page and echo the html form file in another directory, also trying simple dhtml codes.
unfurtunately I didn't receive any answer that could satisfy me, I need also to put a form in some of product pages and when the client order the content of the form be sent along the order.
so, the issue of using form in contact us, also couldn't help me as for every product the form is different.
another issue is that using attributes seems to be the best way, BUT I didn't get and find any post HOW can we arrange the order of the attributes in product page. you may never get a form like your in your png file by attributes,
I hope somebody can help us.
success