Create interactive PDF from a DOCX that emails once completed

I have a word docx document that needs to be converted into an INTERACTIVE PDF that users fill out and press SUBMIT. It needs to send as an email once user has filled out all the blanks. There are 2 drop down boxes needed to be added. And with one of those drop down boxes, it will determine where the email is meant to go to. IE: If someone selects VICTORIA it will be emailed to VICTORIA[at][login to view URL] . If someone selects NSW the pdf will go to NSW[at][login to view URL] . I will provide the drop down boxes and email address destinations. Use of extended features must be enabled. Will pay maximum $10. Must be completed within 4 hours of job acceptance.