The form seems to work fine for me, however none of my Republic characters from the server The Harbinger are showing up. My Imperial characters on Mandalore the Indomitable are all there (which is odd as they were created after my characters on Harbinger).
The originating server which you want to transfer characters from
The Harbinger
The server you want to transfer the characters to
Dalborra
The name of a characters on that server
Allectus
Justinian
Vipsanius
Your specific issues with the form - buttons not available, dropdowns not working, etc
Characters from The Harbinger don't appear.