This looks inspired by the @civicdesign voter registration form, or at least borrows its organizing grid...https://twitter.com/srl/status/1296150894065655809 …
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We worked on the NC ballot request form. It's genealogy is: PA voter registration form (by CCD for PA DOS) vv PA ballot request form (created by PA DOS) vv NC ballot request form (by NC + CCD)
PA says the form has worked well with few problems for voters. There's a version on https://civicdesign.org/tool-kit-for-scaling-up-vbm/ … any state can build on. (It's in Word for working out the text and layout, but we recommend InDesign for final versions and to make an accessible fillable form.)
