Hello, I can develop a fully responsive geolocation validation form for your WordPress website which will be similar to the reference website where user enters his information and is compared with geolocation zone where service is available as per your requirements. I am senior WordPress developer and I am absolutely sure that I can do the project very well. Share the link to your website.
Lets have a quick chat to discuss further.
I have extensive experience in designing and development of Websites, Mobile Applications, Management Systems and E-commerce or Online Stores Solutions.
Kindly have a look at my Portfolio and Client's reviews via this link,
https://www.freelancer.com/u/junkyfunky
Thanks,
Faizan A.