DUX 10-second Survey

The 'Request for Purchase' form is a default form we would provide to libraries who would like to use it (libraries would also have the option to link to a form on their own website).
 
How would the form work? When patrons fill it out, libraries would receive an email (no going through Workflows, this is a good old-fashioned email form).The form would prompt patrons to log in and it would automatically collect their Library Card Number and Name. The rest of the fields are up for debate! We'd like to get your feedback on the fields for the form that would be most useful for you and your patrons.
 
To view the form, open this link to the wireframes in a new window or tab: 
https://g1zz3j.axshare.com/#c=2
 
Keep in mind that wireframes are a digital sketch and not a fully functional website.
 
Please look at the format field, ‘I’d like a…’ and answer the next two questions. (Be sure to open the link above in the instructions).
Are the ‘sub-formats’ needed? (audiobook, etc. that appear when you select a format) *

Answer these questions about the rest of the fields.
Are there any fields that can be eliminated? *
Are there any fields missing that are needed? *