\documentclass{article}

\usepackage{hyperref}

\begin{document}

\begin{Form}[action={http://your-web-server.com/path/receiveform.cgi}]
\begin{tabular}{l}
    \TextField{From } \\\\  
    \TextField{have 1} \\\\  
    \TextField{have 2} \\\\  
    \TextField{have 3} \\\\
    \TextField{finally show} \\\\
    \CheckBox[width=1em]{Has the polynomial as many solutions as its degree ? } \\\\
    \Submit{Submit}\\
\end{tabular}
\end{Form}



\end{document}

