Creating an editable form

I'm creating a course around inclusion and diversity and I want to ask the learners to commit to various actions around inclusion and diversity. I want them to check a commitment area and then submit their commitment. At this point a form will display where the leaner will fill in the details of their commitment. The form will then be saved so the learners can upload it to a SharePoint site. Once they complete and upload the form they will come back to complete the course. I have attached a ppt concept of what I'd like to do.

Any guidance would really be appreciated.

Thanks much,

Jim