This is a typical order form for an American newspaper subscription. An order form for a magazine would be very similar.
Sample:

Task:
Design a new order form according to the following information.
Write an order form for an American monthly magazine which costs $12.00 per year. Assume that the magazine is called “Harper’s Magazine” and that it claims to be America's best source of fact, thought, opinion, and humor. At the newsstand it costs $2.00 per month, so 50% can be saved on a year's subscription. The magazine's actual address should appear at the bottom of the order form. It is: Harper's Subscription Department, P.O. Box 7511, Red Oak IA 51591, USA.