Help to design a form on CC 3.10

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I need to add a form that will allow my customer to input information along with their business card order.

example:

Company Name:

Company Message:

Full Name:

Job Title:

Fax / Other:

Email / Other:

Address Line 1:

Address Line 2:

Address Line 3:

These items they would fill out and then submit when they order their business cards.

I would also need the information to show up the the order form when the order is placed with cubecart

See Sample Card: