First thing: The answer I'll give you is using jQuery.
To access the value of an input field using jQuery, make sure that you have set an id for each of them. Then, inside your javascript code, access the value as follows:
var input_value = $("seu_id").val();
To add these values to the form, ideally, when you click "Click Here", retrieve all the values from the input fields, and seven of these values in the fields of your form. For this, you must define blocks of text in your modal, each with an id. Assuming you have an input field with your name, and you want to send it to the modal. Assuming your modal has a parchment as follows:
<p id="nome_modal"></p>
And that in your form you have an input field defined as follows:
<input type="text" id="nome disabled />
Using jQuery, you will:
var nome = $("nome").val();
$("#nome_modal").text(nome);