form , entering name and check boxes reminder

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hellhello dears, i want to know how to create a form to simplify data entry process then print , for example a form with 3 fields, f name, l name, age

then check boxes : 1 and 2

if check box 1 is checked the page with that person name will be printed and will fill a CALL DATE 3 (dates), today, after 3 months, after 6 months, and after 12 month,

and if check bo 2 is checked will fill the APPOINTMENT date, with same 3 dates,

both checkboxes can be selected, and if possible how to add that to a pretyped template.... ??

i´m new to VB, so it is too complicated to me.....

thx in advance:help

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i need something to that post forum/showthread.php?t=38029

but more complex, and i want it create new document with template (a blank page with header)