iPad Simple Application

Hi, I want to design an iPad Or Android application which will do basically two things 1. Enter patient details when he attend for the first time to the clinic (as per the attached form), these details are: 1. Mobile Phone Number 2. Email Address 3. Name in English 4. Name in Arabic 5. Gender (Male / Female) 6. Nationality (list will be provided for code matching and should be changeable)) 7. Date of Birth 8. Doctor (list will be provided for code matching and should be changeable) 9. Home phone No. 10. Emirates ID 11. [login to view URL]: 12. Address 13. Patient groups (list will be provided for code matching and should be changeable - multi selection could be made) 14. Health issues (list will be provided for code matching and should be changeable - multi selection could be made) 15. How did you know about us (list will be provided for code matching and should be changeable - multi selection could be made) 16. Face picture if could be captured using device camera 17. Patient signature (Very Important) 2. I want the application to be used for Disclaimer purpose, as I want to upload any document and have the patient electronically sign it using a pen and upload the whole doc as JPEG or PDF to the server 3. I want to make a survey page and we should keep it simple like having 5 questions with scaled answers from 1-5 along with some generic info like age, gender, residence city. I need all the info to be saved and transmitted instantly to the server through the wifi and to be directly inserted in SQL Server tables so that I can read them in my application.