sure, just alter the plugin to your needs. you will need to know js(for required), html(add more fields, selectable), css(style). and as that plugins author has been inactive for sometime, you may need to get help on github.
I'm pretty much done downloading and learning new plugins. so I'm not sure how much database you'll need to alter.
just think of the form... copy one field and change the name to what you want, delete the fields you don't want.
in js file make what ever field you want or don't want required and make sure it's the same in the form.
I really can't explain anymore then that without actually doing the work for you, not going to happen, it really is simpler then you think.