Are there possibility to create field with the plugin?

Hello,

This is a question Pre-sale for the plugin WooCommerce Coupon Box. I have a customer that need the possibility to insert this field in the form of Popup:
1. Email Address
2. First Name
3. Last Name
4. Country
5. State
6. Language checkbox

Is there this feature?
Because the customer have the need to get this information not only the email field.
Thank you
L.