Service Desk best practices for logging firewall changes.

We want to create a form in service desk for users to submit requests for firewall access. The fields screen need to have source IP, destination IP, source port, destination port, and protocol for several rules. Seeing as JIRA screens are built vertical, this will make the form very long. Especially for multiple rules. Can someone recommend a clean concise way of doing this? Is there an ad-on (I'm OnDemand) that I could use?

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