Need example of survey made with Word

[dmcdivitt]

I need an example of a survey made with Microsoft Word. A user group at a state agency wants to use a Word document to survey facilities they regulate. The document should function like a PDF form with fields to fill out. When finished with the survey a button will email the document. People will view the document and a process will extract information from the document. I have proficiency with VBA, Office products, and automation but have never made a document having this use. Templates I found online did not have fixed fields for data entry.