Yes, the custom form builder in Vantage will definitely allow you to create the form with the information you need as described. You can have a look at the specific part of the Vantage admin dashboard for this
here, and as you can see, not only can you create text fields, but you can add checkboxes, radio buttons, and dropdown lists as well. It's a fully functioning demo, so although you can add the fields and see for yourself how you build a form, it will not save (but trust me, it works ;)). Thanks.