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How can I Create custom pop up dialog box with question/answer

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I need to create a pop up dialog box that asks a question and accepts an answer input.  The form needs to be able to be emailed out (not server based)  Can someone help me do this?  I am a designer,  with very (Very!) limited coding skills.   Looks like the windjack program that I keep running into does not work with Acrobat X.

Thanks for any help you may have

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