Creating a Dynamic Stamp

Hello All,

I am in the process of trying to create a dynamic stamp. This is a first for me.

I've followed the tutorials, but can't seem to figure it out.

Ideally, I would like check boxes, but it looks like that it not an option. Maybe a prompt box that pops up?

I have attached a picture below of the stamp I am trying to create..

Thank you in advance for your help.