This register has nothing to do with Google. It is an independent list of all users who have had issues ordering a new Nexus 4 device.
You will need to check your confirmation email for details, alternatively you can log in to Google Wallet to find out.
I have made some questions a requirement, this is to enable us to get the best message across to Google. Other than this you are under no obligation to provide any personal details. I will only pass the list of data on to Google, but I shall report a summary as appropriate.
If you want to get in touch, you can do so by sending an email to firstname.lastname@example.org