This form is in Spanish but you can follow the translations below or try Google Translate. After you submit the form it will say “Gracias por participar” That means “Thanks for participating”.
Here are the translations:
Nombre = Name
Apellido = Surname
Dirección = Address
Ciudad = City
Estado = State
Código Postal = Postal Code
Teléfono = Phone
Correo electrónico = Email
Fecha de Nacimiento = Date of Birth
Estado Civil = Marital Status
Sexo = Sex