So here's my test transaction from last week sent to the burn address.

Is "Input" the address I should be listing in the google form?
that is correct because that is the address you are sending Octocoin from to the burn address

so you'll take that address and the total amount you burn along with your Counterwallet address that you create and submit on the form. once the burn phase is over, we look at the amount of Octocoin you sent from your address to the burn address and send the same exact amount of OCTO to your Counterwallet address you provide.
like i said before. i urge you all to save your Counterwallet pass phrase and/or short password you create and your private keys on two separate places besides your hard drive. i'd suggest a USB key, external hard drive, paper wallets, etc.
if you lose this, you lose your OCTO. we have no access to the web wallet. i save mine in multiple places. i assume once they create the desktop wallet it may work sort of like a regular bitcoin wallet but who knows. you'd have to read more into that. bitcoin and other altcoin wallets, you need to save the wallet.dat file.